Kavita Deepchand
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SUMMARY
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The relationship between diet and health is widely accepted. A well-balanced diet is essential to good health. Conversely, poor eating habits can play a significant role in mortality from heart disease, stroke and cancer, which together account for two-thirds of premature deaths in Scotland.1 In addition, inappropriate nutrition is also associated with a wide range of other health problems including diabetes and tooth decay.
The causes of coronary heart disease (CHD) and its possible relationship to diet have been of great concern. A number of committees, including the Committee on Medical Aspects of Food Policy (COMA), have published reports on diet including recommendations on dietary changes to decrease the incidence of CHD.2 In 1994 the Scottish Office announced a series of targets for dietary improvement in Scotland by the year 2005.3 These targets apply to food groups (rather than to specific foods) and specify the average weight for optimum consumption by the population. The Diet Action Group was established to help achieve these targets and an Action Plan for Scotland was drawn up outlining a number of key national dietary targets based on the findings of the 1993 James Report. This report found that the Scottish diet lacks certain vitamins and fibre and contains an excess of saturated fat, refined sugar and salt. The broad goals for the year 2005 are to:
double the intake of fruit and vegetables
increase consumption of wholemeal and brown breads
double the daily intake of breakfast cereals
reduce the intake of total fat, especially saturated fatty acids
reduce average sodium (salt) intake
ensure the intake of non-milk extrinsic (NME) sugars does not increase
increase the intake of non-sugar carbohydrates
maintain consumption levels of white fish and double that of oil rich
fish.4
The Health Survey included a series of questions on informants’ reported eating habits, particularly with regard to milk, fat spreads, bread, breakfast cereals, sugar, salt, fruit, vegetables and dietary supplements. The detailed information collected for these food types is shown by social class and age in Tables 3.1 to 3.31 and by region in Tables 3.33 to 3.63. Table 3.64 shows a few comparisons in reported eating habits between Scotland and England, and Table 3.65 highlights some differences by age (in Scotland). In this chapter, the food types have been grouped together in a number of broad categories for discussion: foods containing sugar (Section 3.2) and fat (Section 3.3); meat and poultry (Section 3.4); fish (Section 3.5); foods with fibre and starches (Section 3.6); fruit and vegetables (Section 3.7); salt and dietary supplements (Sections 3.8 and 3.9).
The questions in the Health Survey deal with reported behaviour relating to the consumption of certain foods and aim to give a broad indication of the population’s eating habits. Much more detailed information on diet is collected in other surveys which cover Scotland and England, notably the National Food Survey and the biennial national diet and nutrition surveys carried out among different age cohorts.5 (However, sample sizes for Scotland in these other surveys are not large enough to permit detailed sub-group analysis.) Biological measurements of some aspects of nutritional status - including total cholesterol, HDL-cholesterol, ferritin, haemoglobin and vitamins - were measured and the results are presented in Chapter 9.
3.2 consumption of foods containing sugar
Sugars are important in providing energy and for the maintenance of life. As well as occurring naturally in fruit, vegetables and milk, sugars are used in a variety of products such as biscuits, cakes, confectionery and beverages. Foods high in NME sugars tend to contain few other nutrients. The prevalence of dental caries is directly related with the amount of NME sugar in the diet.6 The target for sugar is that the intake of NME sugars (such as honey and table sugar) should not increase.
Informants were asked whether they added sugar to tea and coffee. Significantly lower proportions of women than men said they did (27% compared with 50% for tea and 32% compared with 55% for coffee). Those aged 16-44 were slightly more likely than those aged 45-64 to add sugar to tea (51% compared with 46% for men and 29% compared with 23% for women, respectively). Table 3.1, Table 3.2
There was a strong relationship between social class and self-reported use of sugar in tea and coffee. Men in Social Classes IV and V were most likely to say they added sugar to tea (60%) while those in Social Classes I and II were least likely to do so (38%). Among women, 38% of those in Social Classes IV and V said they added sugar to tea compared with 16% in Social Classes I and II. Similar social class patterns were also found for adding sugar to coffee.
3.2.2 Biscuits, cakes and confectionery
Foods such as biscuits, cakes and confectionery tend to be high in both sugar and fat. Informants were asked how often they usually ate biscuits, cakes and confectionery and, for those who said more than once a day, how many cakes or biscuits they usually ate in a day. In summary, the following patterns were found:
the proportions of informants who reported eating these items every day were: over one in three (37%) for biscuits, one in twelve (8%) for cakes and one in four (26%) for confectionery;
there was little variation between the sexes in self-reported frequency of eating these foods, although men were more likely than women to report eating biscuits five or more days a week (47% compared with 40%); among informants who ate biscuits daily, men reported eating more biscuits per day than women (38% of men said they ate four or more a day compared with 24% of women);
people in the oldest age group, particularly women, were most likely to say they ate biscuits and cakes every day; it was the youngest informants, on the other hand, who were the most likely to eat confectionery every day;
in all age groups, women were more likely than men to eat confectionery every day.
There were few significant differences in the self-reported frequency of eating biscuits, cakes and confectionery by social class. There was a slight tendency for those in Social Classes I and II to be less likely than average to eat biscuits and confectionery every day. Table 3.3, Table 3.4, Table 3.5, Table 3.6, Table 3.7
The Health Survey also included questions on the frequency of consumption of crisps and savoury snacks, ice cream and soft drinks. Table 3.8, Table 3.9, Table 3.10
3.3 consumption of foods containing fat
Fats are a concentrated source of energy which means they are high in calories. Fat also helps in the absorption of vitamins A, D, E and K. Sources of total fat intake include milk and fat spreads (reported on in this section) as well as biscuits, cakes and puddings (described in Section 3.2) and meat and meat products (which are covered in Section 3.4). Too much fat, especially saturated fatty acids (SFA) is associated with raised plasma cholesterol levels and risk of CHD.7
The targets set out in the Diet Action Plan for Scotland are to reduce by the year 2005 the average intake of total fat from the current 40.7% to no more than 35% of food energy and to reduce the average intake of saturated fatty acids from 16.6% to no more than 11% of food energy. Part of this target is to reduce butter intake by two-thirds and to replace saturated fat margarines and spreads with low saturated fat equivalents.
Fat spreads include butter, margarine and other spreads. While the fat content of these spreads varies considerably, hard fat spreads, such as butter and some hard margarines, have a higher SFA content than soft, polyunsaturated margarines or reduced fat spreads.
Informants were asked what type of fat spread they usually used on bread. Most popular were reduced or low fat spreads used by nearly half of informants (49%); just under one quarter of informants (23%) stated that they usually used a hard fat spread; a similar proportion (22%) used a soft margarine.
Compared with those aged 16-44, higher proportions of both sexes aged 45-64 reported using hard fat spreads (20% compared with 28%). Informants in Social Classes I and II were the most likely to say they used butter or hard margarines. Table 3.11, Figure 3A
Figure 3A: Usual type of fat spread, by age and sex
The fat content of milk varies according to whether it is skimmed, semi-skimmed or whole, and the Health Survey asked what kind of milk people usually used for drinks, in tea or coffee, and on cereals.
In the Health Survey, higher proportions of women (70%) than men (64%) stated that their usual type of milk was either skimmed or semi-skimmed. There were no significant age differences in usual type of milk consumed.
There was a strong association with social class for both men and women: those in manual social classes were much more likely than those in non-manual social classes to report using whole milk. Table 3.12
Cheese also varies considerably in fat content, and the Diet Action Plan aims to encourage people to switch to low fat cheeses. The Health Survey asked informants how often they ate cheese (not including cottage cheese or other reduced fat cheeses).
About one in four (23%) informants said they ate cheese five days a week or more. The vast majority of informants ate cheese two to four days a week (39%) or less often than that (38%). Table 3.13
Overall men reported eating cheese slightly more frequently than women. Informants aged 16-44 were more likely than those aged 45-64 to report eating cheese on five or more days a week.
Fat derived from meat provides around one quarter of the total fat and SFA intake of the Scottish population.8 A reduction in the consumption of meat fat, particularly in meat products, is therefore seen as an important step in reducing diet-related mortality in Scotland.
Meat
Informants were asked how often they ate meat, such as beef, lamb or pork. Overall, 5% of informants reported eating meat at least once a day, 57% on 2-6 days a week, and 38% once a week or less. Women reported eating these types of meat less frequently than men (44% compared with 32% reported eating meat once a week or less). Table 3.14
Informants aged 16-44, particularly women, reported eating meat less frequently than those aged 45-64: 50% of women aged 16-44 said they only ate meat once a week or less, compared with 34% of women aged 45-64; the equivalent figures for men were 34% and 26% respectively.
Meat products
Meat products (bridies, sausage rolls, meat pies, etc.) contain high levels of hidden fat and should be limited in order to reduce the intake of total fat consumption. The target is to halve current consumption of such meat products by year 2005.
Frequency of consumption of meat products was as follows: 7% of the sample said they ate meat products five or more days a week, 29% on 2-4 days a week, and 64% once a week or less. Women reported eating these meat products much less frequently than men (74% of women said they ate these products once a week or less compared with 54% of men).
Reported consumption of meat products also varied significantly by age, with older informants much less likely to say they ate these products than younger ones. Among men, 65% of those aged 45-64 said they ate meat products once a week or less compared with 48% of 16-44 year olds; among women, the differences were less marked, with 79% of 45-64 year olds eating meat products once a week or less compared with 70% of women aged 16-44. Table 3.15
There was also a very strong association with social class, with the likelihood of eating meat products more than once a week being much higher among manual than non-manual social classes.
Women were a bit more likely than men to report eating poultry on at least two days a week, but the difference was not large (54% compared with 50%). Age differences were also small, although men aged 16-44 were more likely than those aged 45-64 to say they ate poultry on two or more days a week.
There were quite large differences by social class, with informants in the non-manual social classes much more likely to say they ate poultry on two or more days a week than those in the manual social classes (60% compared with 45% respectively). Table 3.16
Higher consumption of fish, in particular oil-rich fish, has been shown to be associated with reduced mortality from CHD and improved blood lipid profiles.9 The Diet Action Plan for Scotland has set targets for consumption of white fish to be maintained at current levels whilst doubling the consumption of oil-rich fish from 44 to 88 grams per week. Overall, the aim is for 50% of the population to eat fish twice a week.
Around half of informants in the Health Survey reported eating white fish (cod, haddock, whiting, sole, plaice, etc.) once a week or more (54% of men and 53% of women). For both sexes, older informants reported eating white fish more often than younger informants. Table 3.17
Self-reported frequency of consumption of oil-rich fish (herring, tuna, mackerel, salmon, kippers, etc.) was much lower than for white fish. Overall, 36% reported eating oil-rich fish once a week or more (33% for men and 39% for women). Informants aged 45-64 said they ate oil-rich fish more often than those aged 16-44.
The likelihood of eating oil-rich fish varied by social class, with those in manual social classes much more likely than those in non-manual social classes to say that they rarely or never ate oily fish. Table 3.18
3.6 consumption of foods containing fibre and starches
Foods which are high in fibre and starch supply energy and nutrients with very little fat. Breakfast cereals (and other cereals in the form of bread, pasta and rice) are a major source of energy in the diet. They are important sources of many minerals, including iron, as well as vitamins and dietary fibre. Fibre is also present in fruit and vegetables (described in Section 3.7).
Wholemeal bread tends to provide more fibre than other types of bread. The dietary targets for Scotland state that current daily bread intake of 106 grams should increase by 45% by year 2005, mainly using wholemeal and brown bread.
Informants were asked which type of bread they usually ate and the number of slices of bread or rolls they usually ate per day. Among those informants with a usual type of bread,10 white or soft grain bread was the type mentioned most often by informants (69% of men and 58% of women). Next most popular was wholemeal bread (23% of women and 16% of men), with brown, granary and wheatmeal the least often mentioned (19% of women and 15% of men).
Women aged 16-44 were more likely to report eating wholemeal, brown and granary bread than those aged 45-64; the opposite was found among men. Table 3.19
There were also significant variations in type of usual bread eaten according to social class, with those from non-manual social classes much more likely than those from manual social classes to report eating wholemeal bread. For example, informants in Social Classes I and II were more than twice as likely to report eating wholemeal bread than those in Social Classes IV and V (23% compared with 11% for men and 35% compared with 16% for women).
Men reported greater consumption of bread than women: over half (54%) of men said they ate four or more slices of bread or rolls each day compared with one in four (27%) women. The majority of women (55%) said they ate 2-3 slices of bread or rolls each day. Table 3.20
For men, there was a clear association with age, with younger men reporting greater bread consumption than older men, but this did not apply to women.
Both men and women in Social Classes IV and V reported eating more slices of bread than those in Social Classes I and II (for example, 64% of men in Social Classes IV and V said they ate four or more slices a day compared with 43% of men in Social Classes I and II).
Breakfast cereals provide many nutrients including fibre, minerals and vitamins. However, there is significant variation in the fibre content of breakfast cereals, with some containing only negligible amounts. The dietary target for Scotland for the year 2005 is to double the current average intake of breakfast cereals to 34 grams per day.
Informants were asked which type, and how often, they usually ate breakfast cereals. Their responses were coded into one of two categories: high fibre cereals and all other types.
Over two-thirds of men (68%) and women (71%) said that they usually ate breakfast cereals. Table 3.21
Higher proportions of those in non-manual than manual social classes reported eating breakfast cereals.
Among men who said they ate cereals, under half (44%) usually ate high fibre cereals (50% for women). Informants of both sexes aged 45-64 were much more likely to say they ate high fibre cereals than the under 45s.
Men and in Social Classes I and II, and women in Social Classes I, II and IIINM, were more likely to say they ate high fibre cereal than those in the other social classes.
Nearly two-fifths of men (37%) and women (39%) said they ate breakfast cereals every day. Table 3.22
Informants in non-manual social classes were more likely than those in manual social classes to say they ate breakfast cereals daily.
3.6.3 Potatoes, pasta, rice and chips
Potatoes, pasta and rice, which contain non-sugar complex carbohydrates, are a major component of people’s diets. The proposed dietary target for total complex carbohydrates is to increase the current intake of 124 grams per day by 25% by year 2005 through increased consumption of fruit and vegetables, bread, breakfast cereals, rice and pasta. Potato consumption is targeted to increase by 25%. Greater intake of these commodities is also an appropriate substitute for calories derived from fat.
Informants were asked how often they ate potatoes (excluding chips), pasta or rice. Approximately one in three informants said they ate potatoes, pasta or rice once a day or more (32% of men and 37% of women), and a further one in five said 5-6 days a week (21% of men and 22% of women). Table 3.23
Among both sexes, informants aged 45-64 were more likely than those aged 16-44 to say they ate these foods every day.
There was also a strong association with social class, with informants in Social Classes I and II the most likely to eat potatoes, pasta or rice on a daily basis.
Reported consumption of chips was much higher among men than women, with half (51%) of men saying they ate chips two or more days a week compared with one-third (35%) of women. There was also a significant association with age, with 16-44 year old informants reporting more frequent chip consumption than those aged 45-64. Self-reported chip consumption was also much higher for informants, especially men, from manual than non-manual social classes: for example, the proportion of men saying they ate chips on two or more days a week increased from 37% in Social Classes I and II to 65% in Social Classes IV and V. Table 3.24
Many pulses have a high fibre and starch content. When asked how frequently they ate pulses (such as baked beans, dried beans and lentils), around half said they did so on two days a week or more (53% men and 48% women), while three-quarters of men (78%) and women (73%) said they did so at least once a week. Table 3.25
For both sexes, higher proportions in the younger age groups (16-44) reported eating pulses at least once a week (which is probably accounted for by consumption of baked beans).
Informants in manual social classes were a bit more likely than those in non-manual occupations to report weekly consumption of pulses.
3.7 consumption of fresh fruit and vegetables
High intake of fruit and vegetables can help to protect against ischaemic heart disease and a variety of cancers and intestinal disorders whilst providing a wide range of nutrients and other biologically active components which are increasingly recognised as protective of health. Young adults should be eating three or more portions of fruit and vegetables per day. The dietary target is to double average current consumption of fruit and vegetables to more than 400 grams per day by the year 2005.
Informants were asked how often they usually ate fresh fruit, cooked green and root vegetables, and raw vegetables and salad.
Overall, fewer than half (46%) of informants reported eating fresh fruit every day. Women tended to report eating fresh fruit more frequently than men: 52% of women said they ate fruit once a day or more compared with 39% of men. Although the majority of informants (72%) said they ate fruit at least 2 days a week, one-third of men (34%) and over one fifth of women (22%) said they only ate fruit once a week or less. Table 3.26
Figure 3B: Percentage eating fresh fruit daily, by social class of chief income earner and sex
Informants aged 45-64 were more likely to report eating fresh fruit every day than were those aged under 45.
There was a strong relationship between social class and the self-reported consumption of fresh fruit. Those who reported eating fresh fruit daily increased from 30% in Social Classes IV and V to 47% in Social Classes I and II for men and from 39% to 63% for women. Figure 3B
Just over one in four informants (26% of men and 30% of women) reported eating cooked green vegetables (such as peas, broccoli, cabbage, spinach, cauliflower, green beans, etc.) every day. About one in five said they only ate these types of vegetables once a week or less (23% of men and 18% of women). Table 3.27
Informants aged 45-64 (36%) were more likely than those aged 16-44 (24%) to eat cooked green vegetables every day.
Informants in Social Classes I and II were the most likely to say they ate cooked green vegetables every day; those in Social Classes IV and V, on the other hand, were the most likely to report eating these vegetables once a week or less.
Overall, only 15% of informants reported eating cooked root vegetables (carrots, parsnips, turnips, etc.) daily, while one in three (34%) said they ate cooked root vegetables once a week or less. Informants were most likely to say they ate these vegetables 2-4 times a week (43%). Women reported eating root vegetables more often than men (17% compared with 12% said they ate root vegetables every day). Table 3.28
Informants aged 45-64 reported more frequent consumption of root vegetables than those aged 16-44. Those in Social Classes I and II also reported more frequent than average consumption of cooked root vegetables.
Only very small numbers of informants said they ate raw vegetables or salad on a daily basis: 6% of men and 11% of women. About half the sample said they ate raw vegetables or salad once a week or less (57% of men and 45% of women), while one in three did so on 2-4 days a week (34% men and 38% women). There were no clear age differences in the reported frequency of eating salad. Table 3.29
In terms of social class, informants in Social Classes I and II reported eating raw vegetables or salad much more frequently than those in Social Classes IV and V. Among men in Social Classes I and II, 52% said they ate salad twice a week or more compared with 33% of men in Social Classes IV and V. The equivalent figures for women were 64% in Social Classes I and II and 48% in Social Classes IV and V.
Sodium chloride (salt) is present in all body fluids and small amounts are necessary in the diet.11 Sodium and chloride are not naturally found in high concentrations in foods, but are added to many foods by manufacturers and in the home. It is generally accepted that average salt intake is needlessly high, probably several times higher than the body’s daily requirements. High levels of salt intake are associated with raised blood pressure. The target for the year 2005 is to reduce the average sodium intake from the current 163 mmol to 100 mmol per day.
The Health Survey asked informants whether they added salt to their food at the table. Overall, higher proportions of men (53%) than women (41%) stated that they usually added salt to their food, while a further 19% of men and 22% of women said that they occasionally did so. Moreover, men were much more likely than women to say they added salt without tasting the food first (37% compared with 25%). Table 3.30
Figure 3C: Adds salt to food at table, by social class of chief income earner and sex
Informants aged 45-64 were a bit more likely than those aged under 45 to say they rarely or never added salt.
There was a much stronger relationship between adding salt and social class, with informants in manual social classes more likely to say they added salt to their food than those in non-manual social classes. For example, nearly half of men (45%) in Social Classes IV and V said they added salt to food without tasting it compared with 28% of men in Social Classes I and II (the equivalent figures for women were 33% and 17% respectively). Figure 3C
Vitamins are required in small quantities for growth and metabolism. They are essential substances which (with the exception of vitamin D) cannot be synthesised in the body and are therefore required in the diet. Minerals - including calcium, phosphorus, iron, potassium, sodium, chlorine and magnesium - are also essential for normal functions of the body and required in the diet in small amounts. A varied diet should be sufficient to meet the recommended dietary intake of all necessary vitamins and minerals. For individuals who do not have a sufficiently varied diet (for whatever reason), or who have greater mineral or vitamin requirements, food supplements can play an important part.
During the nurse visit, informants were asked whether they took any vitamin or mineral supplements or anything else to supplement their diet or improve their health (other than those prescribed by a doctor). Overall one in four (26%) women and one in seven (15%) men reported taking a dietary supplement. Table 3.31
Informants aged 45-64 were more likely than those aged 16-44 to say they took a food supplement (18% compared with 13% of men and 32% compared with 22% of women).
Of the dietary supplements taken, vitamin supplements were reported most often (8% of men and 15% of women) followed by fishoils (7% of men and 9% of women).
Some of the largest differences in self-reported eating habits between non-manual and manual social classes are summarised in Table 3.32. It can be seen from this table that informants in non-manual social classes tended to report eating habits more in line with ‘healthy eating’ messages than did those from manual social classes. Table 3.32
The distributions for all the different food types described in the earlier sections are shown by region in Tables 3.33-3.63. In general, it appears that eating habits did not differ greatly by region. Moreover, where there were differences, they tended more often to be found among men than women. The most distinctive region would appear to be the Highland & Islands, as this region was the most likely to differ from the other six regions in terms of self-reported eating habits. Some of the larger regional differences are described below.
Men in the Highland & Islands and Borders, Dumfries & Galloway were the most likely to report eating biscuits and cakes every day.
Informants of both sexes in Borders, Dumfries & Galloway were by far the most likely to say they usually used whole fat milk.
Men in the Highland & Islands tended to report less frequent consumption of poultry (along with those in Borders, Dumfries & Galloway); but Highland & Islands men reported higher than average consumption of white fish and much higher than average consumption of oil-rich fish.
Men and women in the Highland & Islands were the most likely to say they ate wholemeal or brown bread and high fibre cereal.
Reported consumption of potatoes, pasta and rice showed significant variation: it tended to be lower than average in Lanarkshire, Ayrshire & Arran, Forth Valley, Argyll & Clyde and Greater Glasgow, and higher than average in Highland & Islands and Grampian & Tayside.
Informants in the Highland & Islands were by far the most likely to say they ate fresh fruit every day, while those in Greater Glasgow were the least likely to. Similar patterns were found for reported consumption of cooked vegetables, with informants in the Highland & Islands tending to report more frequent than average consumption and those in Greater Glasgow reporting less frequent consumption. Table 3.33 toTable 3.63
The 1994 Health Survey for England included a few questions on diet, covering milk, fat spreads, sugar, salt, bread, and breakfast cereals. Table 3.64 compares the Health Survey results for men and women with the results for 16-64 year olds in England as a whole, and for 16-64 year olds in Northern England (that is, the Northern & Yorkshire and North West region. Compared with England, the main differences were:
Higher proportions of informants in Scotland, particularly men, reported eating
fruit less than once a week.
Higher proportions of men and women in Scotland reported eating biscuits and
confectionery every day.
Informants in Scotland were less likely to say they usually ate wholemeal or
brown bread.
Men and women in Scotland were much more likely to usually add salt to their
food at the table.
Informants in Scotland were a bit more likely to say they used butter or hard
margarine, and were a bit less likely to take dietary supplements.
Significantly fewer informants in Scotland reported adding sugar to tea and
coffee. Table 3.64
3.13 comparisons with the scottish heart health study
The results found in the Health Survey are similar to the findings of the 1984-86 Scottish Heart Health Study (SHHS), which asked informants whether they had eaten any fruit in the previous week (see Chapter 1 for a description of this study).12 For informants aged 40-59 (the age range included in the SHHS), 20% of men and 10% of women said they had eaten no fruit in the previous week. The Health Survey found 21% of men and 11% of women aged 40-59 who said that they ate fruit less than once a week.
Looking at vegetable consumption in the SHHS, 12% of men and 7% of women reported eating no vegetables or salad in the previous week, which is slightly higher than the 8% of men and 4% of women in the Health Survey who said they ate raw vegetables or salad once a week or less.