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REPORT OF THE WORKING GROUP ON MONITORING SCOTTISH DIETARY TARGETS

2. Background

2.1 The Scottish Dietary Targets

2.1.1'The Scottish Diet Report' (The Scottish Office, 1993) contained over forty dietary targets, which were intended as population based targets. These quantitative targets were derived from the 'Dietary Reference Values for Food Energy and Nutrients for the United Kingdom' (Department of Health, 1991) and a series of calculations using combined National Food Survey (NFS) data from 1989-1991. The NFS data was chosen because of the frequency with which data is collected, the survey's consistency, detailed breakdown of food groups and because it was one of the few sources of available nutrient data. The targets in the SDAP were taken from this original list following a consultation process and were chosen as they focused on principal areas of concern of the Scottish Diet. The Scottish Dietary Targets are shown in Table 2 below.

*Progress towards the breastfeeding target is reported elsewhere and therefore the Working Group on Monitoring Scottish Dietary Targets did not consider this target further.

2.2 What Actually Needs to be Measured?

2.2.1 The Scottish Dietary Targets comprise both nutrient and food based targets. Where the nutrient based targets are expressed as a percentage of dietary energy, as is the case for fat and saturated fat for example, the dietary assessment method chosen to monitor progress towards these targets must be capable of measuring total energy intake and therefore total dietary intake. Where the targets are expressed as grams per day, as is the case for complex carbohydrates and the food based targets, then information regarding frequency of consumption and portion size is required.

2.2.2 Since the publication of the SDAP there have been major changes in eating patterns and the range of products available for consumption. In reviewing the monitoring of the targets the Working Group made the following recommendations regarding what should be measured.

2.2.3 Fruit and Vegetables: The baseline fruit and vegetable intakes stated in the Scottish Diet Report were based on fresh and frozen fruit and vegetables but the SDAP target for fruit and vegetables is not limited to these foods. Measurement of this target should be compatible with the 5 a day message (Williams C., 1995).

2.2.4 Bread: Since this target was originally written the range of bread available has increased rapidly. For example 'luxury' breads, such as ciabatta and focaccia, containing higher levels of fat and salt, are now readily available. There are also new manufacturing techniques that means, for example, white bread may contain added fibre, thus increasing its nutritional value.

2.2.5 Breakfast Cereals: The range of breakfast cereals available has greatly increased since the targets were set in 1996. Frequently these new products are higher in sugar, salt and fat than is desirable. The population should be encouraged to eat cereals that are high in fibre and low in salt, sugar and fat e.g. fibre rich flakes and porridge.

2.2.6 Fish: It was noted that the portion size for fish could vary widely depending how it is included in the diet e.g. as a sandwich filling or as part of a main meal.

2.2.7 Fats: The SDAP indicates a target for fat in terms of the relative contribution of fat to total energy. It is possible that in any diet the relative contribution of fat to total energy is appropriate but that the absolute amount of fat consumed is too high.

2.2.8 NME Sugars: This is the only target set specifically for children. Although the age range for children was not defined in the SDAP, for the purposes of this report, an age range from 18 months to 18 years has been assumed.

2.2.9 Total Complex Carbohydrates: The term "total complex carbohydrate" is confusing and should be avoided in the future. The term "non sugar carbohydrate" would be more meaningful in nutritional terms as it may be defined as the sum of starch and non-starch polysaccharide (NSP).

2.2.10 Sodium: It is very difficult to quantify salt intake from dietary records and questionnaires due to the increased use of snack and other processed food, e.g. ready meals, which can have a very variable (but often high) salt content. It is accepted that measuring 24-hour urinary sodium excretion (as a marker of salt intake) is more accurate than calculating sodium intake by dietary assessment methods. However, the Working Group also appreciates that the use of 24-hour urine collections at the population level presents practical difficulties. The outcome of a validation study included in the Health Survey for England (HSE) on the use of spot urine collection to measure sodium intake is awaited.

2.3 Future Scottish Dietary Targets

2.3.1 It was outside the remit of this Working Group to recommend new dietary targets for Scotland. However, in preparing any new dietary targets, the Working Group recognised the need for clarity as well as the importance of considering information provided by up to date scientific reviews and reports by bodies such as the Scientific Advisory Committee on Nutrition (SACN) the World Health Organisation (WHO).

2.4 Appropriate Health Outcomes that will Demonstrate the Effectiveness of Achieving the SDAP Targets

2.4.1 The Monitoring Public Health Nutrition in Europe programme has been set up as part of the development of the European Union (EU) programme on health monitoring ( see Section 5 for further information). It identifies the main causes of morbidity and mortality as cardiovascular diseases, cancer, non-insulin dependent diabetes mellitus (NIDDM), obesity and osteoporosis. The Working Group agreed that the most important health outcomes in Scotland, which may be linked to diet, are coronary heart disease, stroke, certain cancers, obesity, NIDDM and, in children, oral health in relation to NME sugars. As there is a time lag between diet consumption and longer-term health outcomes, interim measurements of risk markers were considered. Measurement of risk markers may be used to provide data predictive of chronic disease and to provide health indicators for the population.

2.4.2 In addition, it should be borne in mind that diet is not the sole risk marker for many of the chronic diseases noted in 2.4.1 as the development of these diseases is multi-factorial.

2.4.3 Sources of data on the health outcomes highlighted in this section can be found in Appendix 4.

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