Policies for a prudent diet

There is a large measure of agreement over the composition of a ‘prudent diet’ - a diet which will both promote good health and contribute to the prevention of specific diseases. The author ex- plains how this is reflected in the sets of dietary goals formulated from the late 1960s by medical and government- appointed committees in a number of Western countries. The obstacles to the uptake of a prudent diet - including advertising by the food companies and the lack of coordination between government departments - are outlined. The article ends with a series of recommendations and observations describ- ing how dietary goals can be translated into comprehensive food policies which narrow the gap between existing and advised consumption patterns.

Keywords: Food consumption patterns; Public health; Food policies

At the time of writing, the author was a research assistant at the Unit for the Study of Health Policy, Guy’s Hospital Medical School, 8 Newcomen Street, London SE1 IYR, UK. She can be contacted at Plan- ning Unit, Block 5, South Wing, St Tho- mas’s Hospital, London SE1 7EH, UK.

Policies for a prudent diet

Linda Marks

‘Whether the object is to avoid cancer, coronary heart disease, hypertension, diabetes, diverticulitis, duodenal ulcer, or constipa- tion, there is broad agreement among research workers that the type of diet that is least likely to cause disease is one that provides a high proportion of calories in whole grain cereals, vegetables, and fruit; provides most of its animal protein in fish and poultry; limits the intake of fats, and, if oils are to be used gives preference to liquid vegetable oils; includes very few dairy products, eggs, and little refined sugar; and is sufficiently restricted in amount not to cause obesity.’

Sir Richard Doll, British Medical Journal’

The emphasis on an overall healthy diet, rather than on the relative importance of particular dietary components in the aetiology or prevention of specific diseases is not new. During the 1920s for example, Sir Robert McCarrison stressed the importance of fresh, unrefined foods as a result of his studies of the Hunzas and Sikhs of north-west India who were free of ‘Western-style’ diseases. He suggested five principal components of a prudent diet: wholegrain cereals, milk and milk products, fresh vegetables and fruit, with meat on occasions. White sugar, white flour and fat were to be avoided. A summary of his conclusions was published in 1936, at a time when the interests of the medical profession were engaged by the chemotherapeu- tic breakthrough heralded by the discovery of the sulphonamides.* Despite the relative lack of interest shown by professionals and policy makers, attention was repeatedly drawn to the associations between ‘diseases of civilization’ and dietary changes, from the 1930s onwards. Initially, much research focused on the dangers of diets high in refined carbohydrates and deficient in fibre. In a review of this literature, Burkitt advanced the hypothesis that the ‘close association geographi- cally, chronologically, and in individual patients between many diseases of modern Western civilisation could be explained on the basis of undigested fibre, in particular cereal fibre, in food’.3

Diets which are low in fibre also tend to be high in fats, (and particularly saturated fats), derive a higher proportion of their protein from animal sources and include foods rich in ‘empty calories’ such as

166 0306-9192/85/020166-9$3.00 0 1985 Butterworth & Co (Publishers) Ltd


sugar products and alcohol. Studies on animals, metabolic studies, clinical studies and epidemiological investigations suggest that such diets have harmful effects on health.

In the 1960s and 197Os, a number of countries responded to such findings by formulating dietary goals intended to encourage populations to consume a more prudent diet. All recommended increases in the consumption of complex carbohydrates and reductions in the consumption of total fat, saturated fats, sugar, and (in some countries) salt. Among the first to act were the medical boards of Finland, Norway and Sweden with the publication of Medical Points of View on the National Diet in the Scandinavian Countries in 1968. Dietary recommendations followed in Sweden4 and Norway.5

Guidelines were also adopted in a number of countries including the USA,6 Finland,7 the UK,* and Canada.’ While there are differences in the size and scope of these reports, and specifically in the extent to which consideration is given to obstacles to healthy eating or to the importance of presenting the public with quantified guidelines, the direction of the information is similar.

These dietary goals differ in origin and content from earlier nutritional advice. Information on recommended daily nutrient require- ments had been developed and integrated into nutrition policy well before this - the League of Nations, for example, had formulated nutritional recommendations for international use as early as 1938.” The dietary goals, however, did not reflect concern over insufficient daily nutrient intake but over a form of malnutrition which resulted from the over-consumption of some foods and the under-consumption of others. They were not derived from studies of nutritional status but from data on food intake and the presumed relationships between changes in food intake and changing patterns of disease. In the first edition of Dietary Goals for the United States, for example it was argued that there was an association between certain dietary factors and six of the ten leading causes of death including heart disease, some cancers, strokes and hypertension, arteriosclerosis, diabetes and cirrhosis of the liver.

The formulation of dietary goals has been accompanied by vigorous controversy - partly reflecting continuing epidemiological debate over the role of dietary factors in the aetiology of specific diseases. In relation to cardiovascular disease, for example, it is recognized that much still needs to be learnt about the relative importance of polyunsaturated and saturated fats and the ratio between them and total fat intake. Such disagreements - often fanned by those who stand to lose from implementation of the goals - have tended to obscure the large measure of agreement between expert committees over dietary risk factors” and over the possibility of developing guidelines for both the general population and high-risk groups. l2

Recent reviews of the relationship between diet and specific diseases have reinforced a ‘prudent diet’ approach. A review of the evidence on diet and cancer by the National Research Council of the National Academy of Sciences’” suggested that while it was not possible to specify a diet that would protect everyone from all forms of cancer, the evidence was such that the public could be offered several interim guidelines, namely, to reduce fat, eat little salt-cured, salt-pickled and smoked food, increase consumption of fruit, vegetables and wholegrain cereals, and to drink alcohol in moderation only.

This article is part of a wider project on prevention funded by the Joseph Fiown- tree Memorial Trust, the Leverhulme Trust, and the Health Education Council. The author was supported by a grant from the Leverhulme Trust. She would like to thank her colleagues at USHP for their helpful comments.

‘Sir Richard Doll, ‘Prospects for prevention’, British Medical Journal, Vol 286, 1983, pp 445-453. ‘W.W. Yellowlees, James Mackenzie Lec- ture, ‘Ill fares the land’, Journal of the Royal College of General Practitioners, Vol 29, 1979, pp 7-21. 3Denis P. Burkitt, ‘Some diseases charac- teristic of modern Western civilisation’, British Medical Journal, Vol 1, 1973, pp 274-278. 4Vidar Hellstrom, ‘Public education on diet and exercise in Sweden’ in L. Hambraeus, ed, Nutrition in Europe, Almqvist and Wik- sell International, Stockholm, 1979, pp 68-74. ‘Royal Norwegian Ministry of Agriculture, Report No 32 to the Storting, On Norwe- gian Nutrition and Food Policy, (1975-76) Royal Norwegian Ministry of Agriculture, Oslo. %elect Committee on Nutrition and Hu- man Needs, United States Senate, Dietary Goals for the United States, US Govern- ment Printing Offices, Washington, DC, 1977. 7Summaty of Reporl of the Finnish Nutri- tion Committee, Ministry of Social Affairs and Health, Helsinki, 1981. ‘Health Departments of Great Britain and Northern Ireland. Eating for Health, HMSO, London, 1978. - ‘Department of Consumer and Corporate Affairs, Food Consumption and Nutrition, DCCA, Canada, 1978. “A.S. Truswell, ‘A comparative look at recommended nutrient intakes’, Proceed- ings of the Nutrition Society, Vol 35, No 1, 1976. DD 1-14. “Re&l of a WHO Expert Committee, Prevention of CHD. Technical Report Series 678, WHO, Geneva, 1982. “Editorial, ‘Diet and ischaemic heart disease - agreement or not?‘, The Lancet, Vol 2, 1983, pp 317-319. ‘%ommittee on Diet, Nutrition, and Can- cer, Assembly of Life Sciences, National Research Council, Diet, Nutrition and Can- cer, National Academy Press, Washing- ton, DC, 1982.

FOOD POLICY May 1985


14The Royal College of Physicians, Medic- a/ Aspects of Dietary Fibre, Pitman Medic- al Ltd, UK, 1980. ‘%oy M. Acheson and D.R.R. Williams, ‘Does consumption of fruit and vegetables protect against stroke?‘, The Lancef, Vol 1, 1983, pp 1191-1193. 16J.I. Mann, ‘A prudent diet for the nation’, Journal of Human Nutrition, Vol 33, 1979, pp 57-63; R. Passmore, Dorothy F. Hol- lingsworth and Jean Robertson, ‘Prescrip- tion for a better British diet’, British Medical Journal, Vol 1, 1979, pp 527-531; John Powles and D.R.R. Williams, ‘Community nutrition and chronic disease’, in Alwyn Smith, ed, Recent Advances in Community Medicine, Vol 2, Churchill Livingstone, Edinburgh, UK, 1982, pp 61-74. _ “Unit for Continuina Education, Depart- ment of Community iedicine, University of Manchester, District Food Policies: Issues, Problems and Opportunities, Manchester, UK, 1982. ‘*Organisation for Economic Cooperation and Development, Food Policy, OECD, Paris, 1981, p 34. “Ministry of Agriculture, Fisheries and Food, Household and Food Consumption and Expenditure, 7980, HMSO, London, 1982. “‘R.W.D. Turner, ‘Butter: the natural choice’, letter to the editor, The Lancet, Vol 1, 1983, p 827. *‘European Commission, Agricultural Re- ports 1981, EEC, Brussels, pp 220-221.

The prudent diet has been recommended for the prevention of obesity; there is further evidence on the relationship between low-fibre diets and disorders of the gastro-intestinal tract14 and, more recently, lack of Vitamin C has been related to cerebrovascular disease.15

The considerable overlap in the dietary implications of such studies eases the task of those concerned with health policy. It is not surprising that in a number of recent reviews of diet and disease the need for a prudent diet has been emphasized.16 On a local level, in the UK, a number of District Health Authorities have formulated such goals for their own populations and services.17

Consumption patterns in the UK

The UK shares with other developed countries a number of dietary trends. There has been a tendency for the intake of calories and other nutrients to be increasingly derived from the indirect consumption of vegetable sources through animal products. In 1977, for example, only Japan, Italy, Turkey and Portugal, of all the OECD countries, derived the greater share of protein per person from vegetable sources.18 The share of calories derived from total fat has increased as has the contribution of carboydrates to calorie intake. Within the sources of carbohydrates there has been a shift from cereals and starchy roots towards sugar and alcohol. In summary, the average dietary intake in the majority of developed countries tends to be characterized by high levels of fats, sugar, salt and alcohol and by low levels of dietary fibre. In the UK information from the National Food Survey” suggests that the UK diet currently contains twice as much fat as that recommended in Dietary Goals for the United States. The highest contribution to saturated fat intake is made by total meats (25.4%), liquid milk (17.2%) and butter (17.2%). It has been argued that the most nutritionally dispensible of all the oils is butter.2”

The problems associated with the National Food Survey are well known: consumption will be underestimated in a number of areas due to the omission of alcohol, and of meals and snacks obtained outside the home (estimated as about 16% of all expenditure on food). Although the consumption of soft drinks is recorded, the contribution made to nutrient intake is excluded from the reports. Clearly, consumption of fats, sugar and salt - as well as total calorie intake - will be underestimated; the UK is even further away from consuming a prudent diet than these data would suggest.

European statistics on the consumption of certain food products provide only a crude indication of actual intake.21 There is no equivalent to a National Food Survey in other countries and comparison is therefore difficult. Nevertheless, with respect to some of those foods singled out as part of a prudent diet there are interesting differences between EEC countries. In the case of cereals, for example, consumption in Italy (1978-79) was 127 kg per person compared with 71 kg in the UK. (UK and Ireland do, however, have the highest consumption of potatoes.) Vegetable consumption in the UK was 83 kg compared with 154 kg in Italy. Fresh fruit consumption was 32 kg in the UK and 86 kg in FR Germany. Though conclusions about the quality of the diet as a whole cannot be drawn from these comparisons, it is clear that the UK’s European neighbours consume more fresh fruit and vegetables, vegetable oils and cereals and far less full cream liquid milk.

168 FOOD POLICY May 1985


The discrepancies between the UK diet, the dietary goals and food consumption in other countries have been considered by some to constitute an important obstacle to the adoption of a more prudent diet. It should be emphasized, however, that the National Food Survey indicates average consumption. This implies not only that there are people consuming a diet which is even further from the dietary goals, but that others are consuming a prudent diet with little difficulty. In some countries, traditional diets are in line with the dietary recommendations; in traditional Mediterranean cookery, for example, fat consumption is lower than that recommended in the USA. Finally, food consumption has changed radically over time, and continues to do so (though not always in a healthy direction).

Obstacles to dietary change

One of the more obvious obstacles to the promotion of a healthier diet has been the slowness - in some countries - in reaching agreement over quantification of dietary goals and thus in developing a coherent policy for the implementation of dietary guidelines. Even where governments have endorsed quantified guidelines, as in the USA, and consumers are presented with unambiguous messages for dietary change, there is little control over the publicity which may be devoted to alternative interpretations of the epidemiological evidence. In a recent analysis of the extent of agreement or disagreement with the dietary goals in the USA, for example, it was found that 90% of government nutritionists supported the goals, compared with only 64% of nutritionists employed in industry.22

In addition, far from being presented with clear messages for healthy dietary change, consumers are encouraged to adopt a very different kind of diet through a combination of advertising, price and production policies. Ways of overcoming the constraints of time, money and availability, though important influences on eating habits, are rarely incorporated into nutrition education.

There is extensive advertising of food products; food manufacturers, as well as the various marketing boards, put considerable effort into advertising certain types of food. In the USA (in 1975) over 1 billion dollars were spent on food advertising and research based on an analysis of food advertising on four Chicago TV stations found that 70-85% of the time was spent promoting processed foods that were generally high in fat, saturated fat, cholesterol, sugar and/or salt.23 Little or no time was devoted to fresh fruit and vegetables - products without the ‘added value’ achieved through processing techniques. Such advertising far outweighs public information on the prudent diet.

In addition to being kept in the public eye through constant advertisement, processed foods gain popularity through being easily available, quick and easy to prepare and, in some cases, cheaper than their fresh equivalents. In the UK, for example the proportion of

22James E. Austin and John A. Quelch, consumer food spending on factory-prepared foods is the highest in

‘Food industry, threat or opportunity?‘, Europe, .24 four-fifths of the food currently bought by the consumer is

Food Policy, Vol 4, No 2, 1979, pp 115- processed in some way. While processing is a crucial factor in the

128. 230p cif, Ref 6, p 59.

provision of adequate supplies, highly processed, convenience foods are

24T.L.V. Ulbricht, ‘What will we eat tomor- not without their nutritional drawbacks - often high in sugar, salt

row? UK food industry and its market’, (between 30-70% of sodium consumed in the average UK diet derives

Food Policy, Vol 4, No 1, pp 57-58. from processed foods) or saturated fat, and low in fibre. The palatability

FOOD POLICY May 1985


of processed foods is not an indicator of their nutritional value and unless manufacturers choose to provide nutrient labelling the consumer will be unable, for example, to monitor the extent of ‘hidden’ fats, sugar and salt in the product. Despite the apparent diversity of processed foods many are derived from a limited number of food components, variety being achieved through processing techniques and various additives. The traditional food grouping systems used by nutritionists have become inadequate for education on food choice when a high proportion of the diet is industrially produced.‘” The comparative nutritional status of highly processed foods - and the nutritional status of those for whom such foods constitute a major part of the diet - require further study.

The relatively high consumption of processed foods is not the only obstacle to a prudent diet approach. The availability, nutritional quality and price of foods is influenced by agricultural policy. Nutritional guidelines issued by Departments of Health are often in conflict with the production policies and targets of Ministries of Agriculture. With few exceptions, agricultural policy is not integrated into a comprehensive food policy. In the UK, for example, premiums do not favour the production of leaner carcasses (except for pigs);26 the production of heavy carcasses which are also lean has been made difficult due to traditional breeds having been selected for fat meat and the intensive rearing of livestock leads to higher levels of saturated fat than do traditional rearing methods. Despite much waste fat being used for meat products such as sausages, it has been estimated that, in 1976, 207 000 tonnes of surplus fat were produced.27

Price policies too are determined by priorities other than health. They may be designed to offset the cost of living, or, in some cases, to reduce surplus stocks. As the food sector is a major part of the economy, proposed changes in the national diet may affect a large number of people, including those who distribute and process food as well as agriculturalists and those who supply agricultural inputs.*’ Each of these will have different priorities. For the farmer, for example, maximization of yield will be the major aim, while for the food processors and distributors a rapid turnover and a larger share of the market will be the major priorities. Clearly, such conflicts of interest will need to be taken into account if a comprehensive food policy is to be implemented.

A final obstacle is the organization of nutrition research. The Agricultural Research Council and the Medical Research Council have been accused of failing to create an effective focus for such research and

25J. Michael Gurney, ‘Selection of an the fragmentation of responsibility between these and other bodies -

optimal diet modern criteria’, in E.F. Pat- such as the food industry - has resulted in both an uncoordinated and

rice Jellife and Derrick 6. Jellife, eds, partial approach. Issues such as the nutritional consequences of Adverse Effects of Foods, Plenum Press, increased consumotion of highlv Drocessed foods or the effects of London, 1982. 26Monica Winstanley, ‘Leaner and leaner

current agricultural practices on the nutrient quality of crops thus

meat’, Nutrition Bulletin, Vol6, No 2, 1981, remain relatively unexplored. pp 74-83. 27Chris Robbins, ‘Health and agricultural policies: a conflict in Kenneth B&low and Peter Bunvard’. eds. Soil Food and Health Towards a comprehensive food policy in a Chanbing korld, A.B. Academic Pub- lishers, London, 1981, pp 55-59. “A. Simantov, ‘Food and nutrition policy.

The social, cultural and economic context of food choice will need to be taken into account if current dietary trends are to be understood and the

What is at stake in the industrialis&d countries?‘, in L. Hambraeus, ed, Nutrition

proposed changes are to be successful. In addition to nutrition

in Europe, Almqvist and Wiksell Interna- information and education a comprehensive approach would ensure

tional, Stockholm, 1979, pp 29-36. that price and production policies were linked to the dietary goals. A


29Michael Tracey, ‘Nutrition policy - an emerging issue for agricultural economists?‘, Journal of Agricultural Economics, Vol31, No 3, 1980, pp 36%379. 3oOp cif, Ref 5. 3’Nancy Milio, ‘Promoting health through structural chanqe. Analysis of the origins and implementation oi Norway’s farm- food-nutrition policy’, Social Science and Medicine, Vol 15A, 1981, pp 721-734. 32Lars Okholm. ‘Dietarv risk factors, Co- op’s responsibility’, pap& presented at the Conference on the Co-op Brand Policy of the Consumer Co-operative Movement in Europe, Milan, Italy, 1981.


number of countries have adopted initiatives in these areas; of these, Norway has come closest to developing a comprehensive food policy. A number of strategies are possible.

Cooperation between government departments

A number of governments have stressed the importance of cooperation between the government departments involved in food and agricultural policy formation. In Canada, for example, institutionalized arrange- ments were set up after the National Food Strategy Conference of 1978.*” The most striking example of such an approach is the Norwegian Food and Agriculture Policy.3” Initiated by the Ministry of Agriculture, and established in 1975, this policy aims to harmonize nutritional and social needs with agricultural production, while also giving attention to the world food supply, as recommended at the World Food Conference of 1974. Self sufficiency is to be increased (to 52% by 1990). In order to promote a healthier diet, certain foods are being restricted but consumer, producer and social needs are considered throughout. No less than eight ministries are involved; an Office of Nutrition has been established in the Ministry of Social Affairs and an inter-departmental, coordinating body has been established. The agricultural sector is now obliged to take the aims of the official nutrition policy into consideration when advertising its products and research is being conducted into ways of producing low-fat meat and milk. Consumer policy measures affect- ing the pricing and availability of certain products have also been developed; consumer subsidies on meat have been reduced, the subsidy on skimmed milk increased more than for whole milk, and the subsidy for poultry set higher than that for pork.“’

Cooperation with industry

Government reports have also stressed the importance of cooperation with the food industry if the implementation of dietary guidelines is to be successful. The food industry can play a crucial role in research into the impact of food processing on the nutrient quality of food, into the safety of additives and in the development of new and nutritionally improved processed foods in accordance with dietary guidelines. It is desirable that ‘ordinary’ foods with reduced fat, sugar and salt should be produced in accordance with these guidelines, and such a ‘mini-risk’ policy has already been adopted by some manufacturers.“* In Sweden, the lo-year Diet and Exercise Programme was developed in cooperation with the food industry, which accepted the recommendations of the group of medical experts appointed by the National Swedish Board of Health and Welfare. Product development was guided by some of the recommendations resulting in a number of new products such as low-fat milk, cheese and meats. Swedish millers and bakers were able to exploit the goal of increasing bread consumption. In contrast, in the USA, the dietary goals were formulated without prior consultation with sections of the food industry and there was significant industry pressure to revise the goals. The National Dairy Council, in particular, criticized the lack of consultation with trade federations and produced a hard hitting document attacking the dietary goals. While it is clear that some food manufacturers will not gain from the implementation of dietary goals, others may benefit from changing consumer demands. The effects of changes in diet on the various parts of the food chain - farmers, processors and distributors - will need to be monitored and suggestions

FOOD POLICY May 1985 171


for change will need to be married with opportunities for diversification through, for example, the encouragement of investment in processing techniques which will improve nutritional quality.

Nutrition education

Where governments have approved quantified dietary goals - such as in Sweden and the USA - clear information can be disseminated to both professionals and the public. In the UK, there is currently no government-approved quantified advice, although a recent discussion paper prepared for the National Advisory Committee on Nutrition Education provides guidance in this area.33 In addition, nutritional training for teachers and health professionals is negligible, and the number of community dietitians is small.“4

The organization of local networks in the formation of community- based nutrition programmes has been successful in both Finland35 and Norway36 and has helped disseminate information on nutrition. In Sweden, implementation of the lo-year nutrition programme was divided between a number of project groups, one of which, Diet and Expenses prepared costed menus demonstrating that it was possible to compose nutritionally balanced meals which were as cheap as traditional menus. Assistants in retail food shops were trained to give customers information on nutrition.

Institutional catering can also provide nutritional meals, whether at school or at places of work. In a number of countries, such as Sweden, free school meals are available and institutional feeding is widespread.“’

Manufacturers in a number of countries have adopted nutritional information as a means of increasing consumer information. The US Select Committee recommended the labelling of ‘invisible’ fats, salt and sugar in processed foods. In Norway, a committee for informative labelling has been established, and there is an annual government grant for improving the output of nutritional information. Thirteen out of 18

33National Advisory Committee on Nutri- expert committees on heart disease recommended the labelling of fat

tion Education, a discussion paper on content on foods.38 Although nutrient labelling of processed foods does proposals for nutritional guidelines for health education in Britain, NACNE, Lon-

not in itself promote the planning of a prudent diet - which would

don, 1984. consist largely of unprocessed foods - it does increase nutritional

34Juliet Gray, ed, Nutrition in Medical awareness, and provides the consumer with the option of avoiding or Education, Report of the British Nutrition Foundation’s Task Force on Clinical Nutri-

reducing the consumption of calories, salt and sugar.

tion, British Nutrition Foundation, London, 1983. Research into dietary changes 35Pekka Puska and Tuula Takalo, ‘Experi- There is a clear need for research into the economic imolications of ences with a comprehensive community- based nutrition programme in Finland’, in changes in diet. In an analysis of the UK in 197439 it was arg’ued that the

L. Habraeus. ed, Nufrition in Eurooe, Alm- recommended reductions in fat would affect imports only, and though qvist and Wikseli International, St&kholm, 1979, pp 83-87.

the increased consumption of cereals and fruit would result in increased

36National Nutrition Council, Inter-sectoral imports, the amount involved was relatively small.

action for nutrition and health Norwegian Multi-disciplinary research is of great importance in the area of policy, (Draft document) 1982. 37WH0 Regional Office for Europe, The

nutrition. One of the McGovern Committee’s five recommendations

Role of Nutrition in Public Health, 1976, was that funds should be jointly provided to the US Department of

WHO, Geneva, p 18. Agriculture and the Department of Health Education and Welfare to 38R W D. Turner, ‘Perspectives in coronary pievention’, Post-Graduate Medical

conduct studies and pilot projects in developing new techniques in food

Journal, Vol 54, 1978, pp 141-l 48. processing and in institutional and home meal preparation aimed at

39M. Allaby, D.M. Baldock and CR Blythe, reducing dietary risk factors; also that a joint committee should be ‘Dietary change, some implications for food supplies, self-sufficiency levels and

established to consider the implications of nutrition and health concerns

import savings’, Nutrition Bulletin, Vol 4, on agricultural policy.

No 1, 1977, pp 12-23. Research is also needed in the consumption patterns of various



groups in relation to the dietary goals. Although the UK National Food Survey provides some of the best information on consumption it does

not, for example provide information on the consumption of processed foods. The relationship between knowledge and food choice and the cultural and symbolic functions of foods need to be explored; currently such research is mainly the province of commercial market researchers. Extra resources will be needed if a better balance is to be struck between advertising and public information.

If dietary goals are to be implemented, a long-term, comprehensive nutrition strategy, integrated into a national food policy, is required. Such an approach has been furthest developed in Norway, where the programme included nutrition education, teaching, agricultural, fishery and price policy measures, consumer policy aspects, food legislation and research and measures involving the food industry. This represents an attempt to respond to the entire nutritional environment and as such provides a yardstick by which more partial or individual approaches may be assessed. Changes in food consumption in Norway between 1974 and 1978 included increases in legumes, vegetables, fruit, grains and skimmed milk with decreases in whole milk, margarine and other fats except butter.

Historically, an all-embracing approach was adopted by the UK during the second world war.4o A Ministry of Food was established; its staff included nutritionists, economists, agriculturalists, food scientists and doctors. Although the measures on rationing are perhaps those which people now remember most clearly, there was also a comprehensive system of nutrition education, prices were fixed, and certain products enriched. In the case of bread, for example, the National Flour was milled to retain a higher level of wheatgerm. The ‘British Restaurant’ set up by many local authorities provided cheap, simple meals and, from 1940, school meals were available. Daily advice was provided for recipes and budgeting; there were food advice centres throughout the country, the media was extensively used and leaflets were distributed. This comprehensive approach become a model for a number of countries after the war.

Conclusions

Many of the debates over what constitutes appropriate nutrition policy rest on the differing emphases attached to the role of individual choice in diet. It is argued, for example, that it is an infringement of the freedom of the individual for governments to manipulate food supplies or prices in order to encourage the consumption of a healthier diet. Nutritional advice is considered adequate for those who wish to modify their diets.

It is true that much advice of an exhortatory nature exists in the area of nutrition. The context within which people make nutritional choices, however, is constantly modified as decisions are made in the areas of price, agricultural, trade and consumer policies, mainly for reasons other than those of encouraging a healthy diet. It has been recognized that a wide range of policy areas affect nutrition, hence the development

40Patty Fisher and Freda Patton, ‘The of intersectoral policies such as Norway’s Food and Agriculture Act. promotion of nutrition and food by the Ministry of Food in 1940-54’, Proceedings

Such ideas go back at least as far as 1945, for the basic idea behind the

of the Nutrition Society, Vol 36, 1977, pp establishment of the FAO of the United Nations was that there should 349-353. be a marriage between health (through better nutrition) and food

FOOD POLICY May 1985 173


production. The FAO requested each of its member states to establish a national nutrition council which should have as one of its functions the task of preparing and implementing an intersectoral nutrition policy for the country.

Despite such recommendations, the implications for health of agricultural practices41 or of techniques of food production and marketing are not generally considered as an integral part of health policy in general or of nutrition policy in particular.

It would be naive to assume that obstacles to the consumption of a prudent diet will be easily overcome as changes would have implications for all sectors of the food chain. Transition would need to be accompanied with measures for facilitating change - in other words, the goals will need to be linked with policies; currently, countries differ less in the nature of their dietary goals than in their implementation and in the extent to which they are integrated with other aspects of food policy.

From a public health point of view, there is little evidence to suggest that a reduced consumption of fat and meat, combined with increased consumption of fruit, vegetables and cereals is disadvantageous - and even less to suggest that the continuation of current dietary trends is without hazard. Current consumption patterns have not been determined on health grounds, and it is true for nutrition as for other areas of

4’Linda Marks, ‘Public health and agri- health policy that individual responsibility for choice should not be

cultural practice’, Food Policy, Vol 9, No 4, allowed to obscure collective responsibility to make such choices more

May 1984, pp 131-138. informed and easier.


Documents

Policies for a prudent diet