Eating for Health: a Diet Action Plan for Scotland

1. INTRODUCTION

Scotland's Diet: The Problem

1.1 The Report on the Scottish Diet, published in 1993, commented that: "Given the clear benefits that can come from dietary change and the evidence from national data on diet and disease that improvements are under way, the issue is how best to accelerate the process in Scotland so that many more people can benefit from improved health."

1.2 The Scottish Diet Action Plan seeks to address this task through a concerted approach to dietary improvement.

1.3 A well-balanced diet is vital to good health. Conversely, a badly balanced diet is harmful and predisposes people to a variety of serious illnesses including diabetes, coronary heart disease and some cancers. Our diet in Scotland is notoriously unhealthy and worse than that of almost any other country in the Western world. Indeed, next to smoking, it is the most significant reason for our poor health record. Children's diets are particularly poor, with many failing to eat green vegetables and fruit. Sugar consumption is high, especially among children, leaving a legacy of tooth decay among all ages, particularly in deprived population groups who neither have the benefits of fluoridation in the public water supply nor compensate for its absence by using fluoridated toothpaste.

1.4 Put into context, death in middle age in Scotland is twice as likely as in many western European countries. Over 2,600 people under 65 die each year from coronary heart disease, over 4,000 from cancers and around 700 from strokes. Our poor eating habits are a significant factor in many of these premature deaths. The probability of dying under the age of 65 is currently 34% greater than in England. Moreover, diet-related disease among the population contributes substantially to healthcare costs in Scotland and to a much reduced quality of life for sufferers.

Recognition of the problem

1.5 The decisive influence of diet on our health was acknowledged by the Government in the 1991 national policy statement, "Health Education in Scotland". For the first time, a policy was articulated which set national priorities and health targets to tackle the main causes of premature death in Scotland; emphasised the importance of healthy lifestyles; and identified the achievement of a better diet as a priority for action. A further Government policy statement, "Scotland's Health - A Challenge To Us All", followed in 1992. This comprehensive document identified a range of initiatives designed to facilitate progress towards the health targets.

1.6 In response to the vital need to improve Scotland's diet, a multidisciplinary Working Party was established under the chairmanship of Professor Philip James, Director of the Rowett Research Institute. The Working Party was charged with the specific task of surveying the Scottish diet and of making recommendations on the improvements required. Its Report, published in 1993, leaves no doubt about the direct relationship between poor diet and coronary heart disease, stroke and cancer and about the disease patterns and premature mortality of the Scottish people being heavily influenced by their dietary habits. The Report concludes that the health of Scots, of all ages, is being adversely affected by an unhealthy balance of diet which is low in cereals, vegetables and fresh fruit but rich in confectionery, meat and dairy products with high saturated fat contents, sweet and salty snacks, baked goods of an unhealthy composition and excessive amounts of sugary drinks. As a result of these eating patterns, the Scottish diet is short of certain vitamins and fibre and contains an excess of saturated fat, refined sugar and salt.

The Government's Response

1.7 The Government accepted the findings of the James Report as an authoritative base from which to proceed. After consultation involving a wide spectrum of interests, including the NHS and other health and dental interests; the agriculture, fishing, manufacturing and catering industries; the retail sector; local authority and community interests; consumer organisations; educationalists; voluntary organisations and Government Departments, a number of key national dietary targets were set for Scotland, based on the Report's recommendations and targets. These targets, for the year 2005, are set out below.

Fruit and vegetables: average intake to double to more than 400 grams per day.

Bread: intake to increase by 45% from present daily intake of 106 grams, mainly using wholemeal and brown breads.

Breakfast cereals: average intake to double from the present intake of 17 grams per day.

Fats: average intake of total fat to reduce from 40.7% to no more than 35% of food energy. average intake of saturated fatty acids to reduce from 16.6% to no more than 11% of food energy.

Salt: average sodium intake to reduce from 163 mmol per day to 100 mmol per day. (It is the sodium rather than the salt (sodium chloride) content of the diet which matters and some foods contain significant quantities of other sodium salts eg sodium glutamate. For convenience, however, and ease of comprehension, reference will be made to "salt" throughout the text.)

Sugar: average intake of NME sugars in adults not to increase. average intake of NME sugars in children to reduce by half to less than 10% of total energy.

Breast-feeding: the proportion of mothers breast-feeding their babies for the first 6 weeks of life to increase to more than 50% from the present level of around 30%.

Total complex carbohydrates: increase average non-sugar carbohydrates intake by 25% from 124 grams per day through increased consumption of fruit and vegetables, bread, breakfast cereals, rice and pasta and through an increase of 25% in potato consumption.

Fish: white fish consumption to be maintained at current levels oil rich fish consumption to double from 44 grams per week to 88 grams per week.

1.8 These targets are challenging. They cannot be met solely by providing further dietary education and advice to consumers, although this will continue to be very important. Nor can they be met from intake of dietary supplements or vitamin tablets. They demand, in addition, the commitment, interaction, co-operation and support of the wide range of interests involved in all aspects of the food chain, both directly and indirectly.

The Action Plan

1.9 The fundamental changes required in the Scottish diet will take time to achieve and will need careful planning and implementation. To facilitate this process, the Secretary of State for Scotland established the Scottish Diet Action Group in November 1994 to develop an Action Plan, with the aim of engaging the commitment and involvement of the wide range of interests in a position to contribute to dietary improvement. The Group was led by the Minister of State at The Scottish Office with responsibility for health matters. Its remit and full membership are set out in the Appendix. The Group was representative of a broad spectrum of expertise - from farmers and other primary producers through to food manufacturers, retailers, caterers, consumers, health professionals, community and education interests and the media. From the outset, despite this wide diversity of interests, a clear commonality of purpose and consensus of view existed within the Group about the need for improvement in the Scottish diet and the approach required to achieve this.

1.10 As the work of the Action Group progressed it became increasingly clear that the most immediate and attainable benefit to the Scottish diet would be an increase in the consumption of fruit and vegetables and of complex carbohydrates from foods such as potatoes, wholemeal bread and cereals. The challenge now lies in ensuring that all sectors of Scottish society recognise both the need to change their diet and the extent of the change required to improve their health and wellbeing. Each sector needs to recognise its role and to contribute to producing an environment where an increase in fruit, vegetables, cereal and fish consumption is readily achievable by individuals throughout Scotland.

1.11 Achieving the remaining dietary targets of reduced intake of fats, salt and sugar may take longer because of significant barriers to change. These include our historically strong attachment to less healthy foods and our cultural reluctance to experiment with new foods and cooking methods and healthier products, although the latter is now beginning to show signs of being less entrenched; the restricted availability of, and access to, high quality fruit, vegetables, fish etc for vulnerable consumers in low income groups; and the predominantly demand-led market philosophy of producers, manufacturers and processors, who have been generally reluctant to initiate new replacement healthy food products because of potential consumer resistance. The Group had little doubt that these barriers could be reduced - some more quickly than others - if the key participants in the food chain were to acknowledge their potential contribution to improving the health of Scotland and work together, with health policy planners and health promotion agencies, to bring the dietary targets within reach by 2005. Such an acknowledgement by the food chain would represent a clear and public demonstration of its social responsibility in seeking to take into account, in its commercial operations, the health and well-being of its customers.

1.12 This Action Plan looks at the changes required in the diet of the Scottish population in general and of particular groups such as those living in disadvantaged areas, pregnant women, babies, pre-school children and school students; it identifies the contribution which the Group considers each of the key interests exercising major influence over the Scottish diet is capable of making to dietary improvement; and it proposes actions for all of them. The key "influencers" are: community organisations consumer organisations Government and its agencies local authorities manufacturers and processors the media the National Health Service primary producers retailers schools the voluntary sector

1.13 A similar programme of action is underway in England to tackle the dietary problems which exist south of the Border. The Nutrition Task Force, established under the "Health of the Nation" strategy (the English equivalent to the Scottish national policy statement of 1992), published its plan of action "Eat Well" in March 1994 and has since been working towards a programme of implementation. Some of that will be undertaken on a GB basis, eg in the areas of product labelling and product development, and this will bring benefits to Scotland.

Role of the Government and its Agencies

1.14 Much of the action to achieve the dietary targets and consequential improvements in health necessarily rests with consumers and the food industry itself. But the task is very great and will be difficult to undertake effectively, and on the timescale needed, without the support of central Government. It is vital to the success of the Plan, therefore, for Scottish Office Ministers, The Scottish Office, and relevant Government agencies to demonstrate their commitment to the improvement of the Scottish diet in principle and in three practical ways - by directly facilitating a better understanding of dietary issues by the general public, the food industry and health and educational professionals; by providing support, (including, where appropriate, resources,) to encourage the key actions and initiatives required; and by closely monitoring and evaluating progress.

Monitoring of progress and evaluation

1.15 A substantial part of the Government's contribution should be provided at working level by The Scottish Office and by Government Agencies. But we propose, in addition, that the Public Health Policy Unit of The Scottish Office Department of Health should have responsibility for monitoring the delivery of the action recommended in the Plan. The Unit should report annually to The Scottish Office Interdepartmental Group on Health Strategy, whose members are senior representatives of each of The Scottish Office Departments including agriculture, industry and education. The Interdepartmental Group should maintain an overview of progress both in the implementation of the Plan and towards achievement of the dietary targets. Reporting mechanisms to brief the Policy Unit and Interdepartmental Group in their task include the recently introduced Scottish Health Survey, together with the National Diet and Nutrition Survey. These will provide an important database from which to monitor and evaluate changes in eating habits over the next 10 years. The first Scottish Health Survey is currently underway and will be repeated at 3 yearly intervals, providing a regular and consistent monitoring mechanism. The first results are due to be published in March, 1997.

Resource Implications

1.16 The Action Plan is a framework for a concerted programme to achieve dietary targets. We cannot impose the tasks we see as important, though we can and do press their case hard. Previous reports have confirmed a willingness on all sides to help improve Scotland's diet. It is already the mission of many in health and education, for example, to do so. For others, in food production and marketing, there are opportunities to shape and respond to market demand as part of a constantly changing pattern of investment and targeting.

1.17 A conventional cost benefit analysis of the resources needed and likely savings within the NHS from effective action would be complex and time-consuming, with the collation and recalculation of a very wide range of both direct and indirect costs. Thus to the conventional costs of hospital and health centre care has to be added the cost of time lost from work, the excess cost of disability pensions, the infrastructure cost of diverting resources to cope with the extra demand, and the social costs of illness within the community. One example of diet-related health costs which has been estimated in several Western countries is that of obesity where 7-10% of total health care costs have been related to this condition, both directly and indirectly, through its contribution to other diseases such as diabetes, high blood pressure and heart disease. In Finland, the costs of treating high blood pressure have fallen in the last 15 years because only a quarter of the numbers previously treated now have this condition. Similarly, premature deaths from stroke and coronary heart disease have fallen by 60-75%. Scotland has, per capita, a substantially higher demand on health care than England and Wales, this reflecting, in part, the extra burden of the diet-related diseases. Such costs will not fall, immediately, however, as dietary changes occur because the corollary of a projected decline in death rates from cardiovascular disease may be an increase in the total numbers surviving with coronary artery disease or strokes. These additional patients will be in need of treatment. A lengthening life expectancy may also bring additional health care costs. The challenge, therefore, is to improve health by dietary means so that there is minimum ill-health until late in life.

1.18 As indicated in paragraph 1.17 the costs and benefits are broader than those relating to the Health Service alone. Although detailed analysis is difficult, it seems feasible that exploitation of new markets for fish, fruit and vegetables, cereals and leaner meat will offer rewards for primary producers which growing demand among more health conscious consumers will boost. Adjusting food products to make them healthier will carry costs for manufacturers, processors and, in some cases, retailers, but, carried out over a period, against the need to respond to changing consumer perceptions and demands which are already evident, they will also bring commercial rewards. Adaptations in training and information for key staff, so that nutrition is better covered, can generally build on courses and opportunities already in place, but there will be development costs.

1.19 A number of early tasks have been identified and costed. For these we recommend funding from The Scottish Office, in particular the appointment of a national project officer to promote and focus dietary initiatives within low income communities within a national strategic framework, the introduction of a pilot scheme providing a low cost (or free) nutritional advisory service for caterers and the issue of a mailshot on healthy eating to all Scottish households. Another large task - the preparation of the Model Nutritional Guidelines for Catering Specifications for the Public Sector in Scotland - has already been tackled; the Guidelines accompany this Action Plan. A great deal can be done with existing personnel and structures. Recurrent investment in new educational, health and other resources can be used to redirect programmes to facilitate dietary change. But some short-term resource will be needed to stimulate initiatives jointly or sequentially in different sectors. We would expect the agencies as well as departments of Government in Scotland to act in support of these recommendations wherever they can.

Timescales

1.20 The Action Plan signposts the way towards achievement of the dietary targets set for the year 2005. The process and pace of change towards that destination will necessarily vary across the sectors concerned. The Plan does not, therefore, set milestones along the route to be reached within rigid timescales. To do so would be impracticable and intrusive. Instead the Group concluded that the various interests involved should be encouraged to initiate the necessary action to set timescales which are practical within their own settings but which result in the achievement of the dietary targets for 2005. The Chief Medical Officer for Scotland and the Public Health Policy Unit will require to monitor closely the action being taken and its progress, and to report annually to the Interdepartmental Group, on Health Strategy.

Terminology

1.21 In this Action Plan we refer, variously, to "healthy" and "unhealthy" foods. This is a form of shorthand for ease of reference for the reader. In practice, there are no intrinsically healthy or unhealthy foods, (other than those contaminated with bacteria or toxins), only healthy and unhealthy diets in which the diet is either well balanced and thus "healthy" or poorly balanced and thus "unhealthy".

Consultation on the Action Plan

1.22 The Group has drawn, in its work, on the great goodwill that was evident following publication of the Report on the Scottish Diet in 1993. The Group's wide span of membership brought expert contributions from food and catering, as well as education and health. This included sectors which are not brought together in Scotland by representative groups. From the Group's collective knowledge and experience have come recommendations with a real impact for good on the Scottish diet. The Group has been further guided by helpful advice from key agencies about particular proposals - designed to test practicality - and acknowledges there too a wide debt. Further discussions will be necessary with the different sectors, as the exploratory steps and developments recommended are completed, and wider action taken on board.

Conclusion

1.23 As we indicate in paragraph 1.12 the proposals in the Action Plan are discussed and presented according to the various sectoral interests and agencies which we believe are capable of exercising major influence on the nature of the Scottish diet. They are many in number. Co-ordinated and concerted action between them will be essential if the dietary targets are to be achieved. The common objective must be to ensure that the barriers to a healthy diet are removed as quickly as possible, and that the public can be encouraged and enabled to make informed and sensible healthy food choices. The Action Plan seeks to address how this objective can be achieved and the dietary targets secured. If the Plan is taken forward effectively, the benefits will be experienced by the whole population within a 10 to 15 year period. But the most significant health gain of all will be the legacy for our children, and succeeding generations, of an improved quality of health and life expectancy.