Eating for Health: a Diet Action Plan for Scotland

5.1 Ultimately, what we eat is what we choose to eat. Choice, however, is dependent on a number of factors, including access to shops and supermarkets; culinary skills; powerful cultural conventions; cooking facilities; awareness of what is healthy and what is not; and, of course, resources. Not all of us have the same scope or ability to select the foods best suited to our health. Geographical, economic, social and infrastructural factors can all be influential and may either inhibit or enhance our capacity to eat healthily.

5.2 For most people in Scotland, access to healthy foods is not a problem. The difficulty lies rather in persuading them that buying and eating healthy foods can be enjoyable and satisfying as well as healthy and inexpensive. Elsewhere in this Action Plan, we describe how this could be achieved.

5.3 Conversely, for many people in the less well off areas, there are a number of real practical obstacles to healthy eating. Not least is the location of supermarkets, access to which normally necessitates the use of a car. These are also the areas where diet is worst and where the incidence of, for example, coronary heart disease is highest. "Scotland's Health - A Challenge To Us All" recognised this dilemma and emphasised that there was a particular need to encourage and enable people living in disadvantaged areas to adopt a healthier diet.

5.4 Some good work has already been done. Health education initiatives at local and national level have focused on low income communities; the Urban Programme has been used to fund a number of projects aimed at fostering healthy eating; and a whole spectrum of community activity, ranging from food co-operatives to community cafes, has been undertaken, often by volunteers. In addition, in order to better inform strategies for dealing with diet within low income communities, the Health Education Board for Scotland has commissioned the Medical Research Council's Medical Sociology Unit in collaboration with the Department of Human Nutrition at Glasgow University to undertake an audit of community food initiatives. This is examining a range of aspects, including funding arrangements, levels of activity, support requirements and the impact of such initiatives on reducing food poverty. It will be important to build on the audit's findings.

5.5 Following a recommendation in "Scotland's Health", The Scottish Office funded local initiatives in four Urban Partnership areas based on local perceptions of how dietary improvement might best be encouraged. In Wester Hailes in Edinburgh, the focus was on schoolchildren, with vouchers issued as part of an incentive system in which points were given for healthy food choices. In Castlemilk in Glasgow, the projects included the production of a local healthy recipe book; funding to community cafes with taster days to encourage participation; and research to establish costs of food purchases in different areas and local perceptions about the availability and price of food. In Ferguslie Park in Paisley, an information folder on diet was distributed to local residents and a minibus and creche facilities were provided to improve shopping opportunities. In Whitfield in Dundee, a kitchen running healthy eating and cooking classes was established, with a particular focus on mothers with young children and the young unemployed. Initial evaluation of the projects has been positive and offers useful pointers to future action.

5.6 All these initiatives are helpful and have a contribution to make. But problems remain and further action is required.

5.7 The Group identified four main, but interlinking, barriers to progress. These are:

limited availability of healthy foods, such as fruit and vegetables, of an acceptable quality and cost.
the difficulty and expense of travelling on public transport to large retailers, eg "out of town" supermarkets, where supplies are usually excellent.
lack of basic cooking skills and equipment.
long established dietary habits and reluctance to experiment with new foods.

5.8 Paragraph 4.7.10 of the Action Plan highlighted the particular problem of access to the large "out of town" supermarkets. The reality is that the range of foodstuffs available in the disadvantaged areas is limited, often lacking in freshness and quality, and sometimes expensive. People in these areas are less likely to have their own transport, thus impeding ready access to supermarkets and stores in other localities stocking quality products at competitive prices. Conversely, economic considerations militate against major retailers locating their stores in these areas. Action is necessary to bring the facilities of the major stores within easy reach. The Group understands that at least one of the major retailers is prepared to explore the possibility of introducing free or low cost transport to the areas in which their stores are currently located. The Group looks forward, with interest, to the outcome of such initiatives.

5.9 Food co-operatives have a continuing role. But their potential is underdeveloped because of difficulties in purchasing food at wholesale prices, and the lack of central purchasing and distribution systems. It may be possible, however, for the central purchasing mechanisms and the distribution channels used by the major stores to be deployed to deliver food to co-operatives, thus saving costs through bulk buying. Existing food co-operatives could group together to facilitate joint purchasing. Such collaborative action is already beginning to take place in some areas and should be encouraged. Specialist expertise from the private sector could possibly be commissioned to advise on purchasing and other procurement techniques.

5.10 Lack of access to reasonably priced products has a knock-on effect. Parents have reduced opportunity to acquire a taste for healthy foods and to develop skills in preparation and serving. This is reflected in the meals provided for their children. Knowledge of the foods which are healthy is not generally a problem - though continuing health education measures are required to maintain awareness - but there is a need for local arrangements which will help develop the confidence of families to buy and serve healthy foods.

5.11 The money available to spend on healthy foods is clearly important for low-income families. Financial constraints discourage experimentation through fear of waste; and the temptation is to rely on foods like biscuits and chips which have proved popular in the past, even though healthy food alternatives are available.

5.12 Mothers and young children in low income communities are particularly vulnerable. As discussed in paragraph 6.2 of the Action Plan, pregnancy is a crucial time for influencing diet for both mother and child and for establishing healthy eating patterns for later life. There is a need, therefore, for health professionals themselves, including community dietitians, to take a greater interest in the diet of mother and child and to work within Health Boards' health alliances to encourage healthy eating by both. More generally, Directors of Public Health should designate individuals on the staff of their Health Boards, who have training in nutrition, with specific responsibility for action to improve the diet of the low income communities in their areas.

5.13 In many respects, problems similar to those in areas of urban deprivation also exist for rural communities, not least those of access to quality healthy food at reasonable prices. But less thought has been given, by comparison, to the impact of deprivation on the diet of these communities. A needs assessment research project commissioned by the Health Education Board for Scotland was undertaken in 1994/95 to investigate factors influencing food choices in an island-based rural community. The research report was published in February 1996. It provides valuable pointers to the action required but it will be important that the particular needs of rural and isolated communities are fully addressed and the remit of the national project officer, whose appointment is recommended in the following paragraphs, should extend to these areas.

5.14 Against this complex background it is clear that there is no quick panacea. What is required is a combination of measures, brought within a strategic framework, which build on existing initiatives and tap into, and stimulate, community initiative and energy. Specific needs will vary from area to area and local plans for dietary improvement geared to local circumstances are essential. There will be mutual advantage, however, in sharing knowledge and experience and in bringing together community action, local authority activity in this area, Health Boards' local health strategies and the activities undertaken by the Health Education Board for Scotland. The Group considers that an effective way of focusing this work would be the appointment of a national project officer, under the auspices of the Scottish Consumer Council, who would have responsibility for the maintenance of a database of activity in collaboration with the National Food Alliance which is to establish a database of food and nutrition-related community initiatives in England. This national project officer would also be responsible for disseminating information and good practice and encouraging information exchange; and for developing ideas for new initiatives in rural as well as urban areas. Resources should be provided by The Scottish Office to fund this post and to support innovative local projects.

5.15 At local level, initiatives to improve diet will often be more effective if undertaken as part of a broader based approach to health issues, which may itself be one component in the comprehensive regeneration of deprived areas. The four Scottish Office led urban partnerships have exemplified the comprehensive approach, in which action to improve housing and the physical environment, reduce unemployment and increase income levels, and tackle social problems such as poor health and low educational attainment, has been co-ordinated in a single regeneration strategy. It is the Government's intention to promote the adoption of such an approach in other areas of deprivation.

5.16 This will be achieved through the implementation of the "Programme for Partnership" policy under which two-thirds of Urban Programme resources will eventually be used to support comprehensive regeneration initiatives in designated Priority Partnership Areas. The remainder will be available to support smaller scale regeneration activity in other disadvantaged areas but, again, with an emphasis on a strategic approach and comprehensive solutions. Local authorities will have a leading role in implementing the new arrangements. The comprehensive approach offers authorities the opportunity to consider, in consultation with those involved in community action and the Health Education Board for Scotland, all forms of action, including diet, to improve health. The Group, therefore, urges local authorities to consider the dietary needs of their respective populations when developing strategies for regenerating their deprived areas. The Chief Medical Officer for Scotland should pursue this in the course of his discussions on public health matters with representatives of the Convention of Scottish Local Authorities.

Action Points

A national project officer should be appointed under the auspices of the Scottish Consumer Council to promote and focus dietary initiatives within low income communities and to bring these within a strategic framework. Resources should be made available by The Scottish Office to fund this post, to support innovative local projects and to sustain and extend successful, effective initiatives.
The role of the national project officer should be to pursue a strategic approach to tackling the problems of people living on a low income, including a responsibility to gather and disseminate information on community initiatives and good practice; to develop ideas for new initiatives; to identify the development potential of existing community action such as food co-operatives; to identify training needs; to work with the retail sector to identify opportunities for action; and to encourage dialogue between Health Boards and local authorities about a strategic approach to food within their areas.
Local community initiatives must continue to be taken, building on the experience gained from the projects funded by The Scottish Office and tapping into community energy and expertise. The health alliances now established in every Health Board area should continue and expand their recent work with the disadvantaged (including rural) areas, stimulating, supporting and synergising community activity.
Directors of Public Health should designate individuals on the staff of their Health Boards, who have training in nutrition, with specific responsibility for action to improve the diet of the low income communities in their areas.
Research should be undertaken into the diet of rural communities to provide a basis from which to develop a specific strategy to support these communities. This research should be related to the work of the Health Education Board for Scotland on community initiatives.
Local authorities should consider the dietary needs of their respective populations when developing strategies for regenerating their deprived areas. The Chief Medical Officer for Scotland should pursue this in the course of his discussions on public health matters with representatives of the Convention of Scottish Local Authorities.