Knock knock: Diet police

It’s happened. What you eat, cook and feed your children in your own home is now a government matter. Pregnant women and mothers of children under 5 will be getting a knock on the door from a government “health visitor” and given “advice on healthier eating.”

Not only that, employers are being encouraged to monitor workers’ weights. Businesses are being provided with government software that workers will have to type in their weight every morning, which will go into a weight surveillance database. Those who gain weight will be flagged for intervention.*

It’s part of the Scottish government’s new $110 million anti-obesity strategy launched by public health minister Shona Robison. As the Scotsman also reported in today’s full story:

Ministers also want to change the way cooking is taught in the nation's catering colleges by getting young chefs to rely less on salt, sugar, butter and cream, and more on healthy alternatives... Additional measures include spending £19m of the total programme on vouchers for fruit and vegetables for women of childbearing age, pregnant women, and children under five in disadvantaged areas, and a review of commercial sponsorship rules to crack down on advertising and promotion of junk food. Ministers will order a retraining programme for midwives and health visitors to ensure that they can give the most up-to-date advice to pregnant women and mothers. In addition, the SNP will launch a "cooking bus", which will tour Scotland giving advice on healthy eating.

Robison said: "Obesity is one of the problems that, like climate change, does not have a simple solution and requires a new way of thinking. If we successfully tackle obesity then we will reduce ill-health, and a healthier Scotland is vital for sustaining and growing our economy."...

The announcement of the decision of NHS Health Scotland to go forward with its anti-obesity Diet Action Plan came at the same time the World Health Organization issued its report finding, not a crisis of ill health, but that Scottish youngsters are healthier and leading healthier lifestyles than kids in most of the entire rest of the world! They’re eating the most fruits and vegetables, too.

Scotland’s public health official’s decision may have come as a surprise, since not only do its own statistics also show there’s been no notable increase in “overweight” Scottish kids for nearly 15 years now, but it had just spent a gob of money on a massive study of its own strategies and they'd proven a total failure!

The WHO Health Behaviour in School-Aged Children study

The new international report from the Health Behaviour in School-Aged Children, WHO Collaborative Cross-National Study: Inequalities in young People’s Health, was just released. This is the most comprehensive cross-national analysis on health-related behaviors and health of young people in 41 developed countries and regions across Europe and North America. It is the fourth in the series of international reports meant to provide statistics to guide public health policies in developed countries. Researchers had surveyed more than 200,000 young people, ages 11-15, in a representative sampling of school children from each country in 2005-6.

The 208-page report found that Scottish children ranked second in the world for ‘healthy eating’ habits and sixth for the amount of vigorous and sustained exercise they did. Some of the reports findings on how Scottish children fared were summarized in the Herald News:

Scots children ‘among world’s healthiest’

Scots children are eating more fruit and leading healthier and happier lifestyles than many other young people around the world, a major health survey has revealed... Researchers found that 11-year-olds in Scotland ranked second in the world for their fruit consumption with 55% of girls aged 11 eating fruit on a daily basis, just 1% behind the Portuguese and compared to 50% in England.

However, the ‘healthy’ diet becomes less popular through adolescence in Scotland, with 40% of 13-year-old girls taking fruit on a daily basis and 34% of 15-year-old girls.

Scots were placed sixth in the international league for [moderate vigorous] physical exercise, with 40% of 11-year-old girls and 25% of boys taking part in at least one hour of activity a day.

The percentage of 15-year olds in Scotland with weights and heights that put their BMIs in the “overweight” or “obese” category, according to new WHO BMI charts, was 12% (girls) and 14% (boys).

As controversial as the efficacy of those definitions are, however, they still proved irrelevant to the growing children because four times that number of girls thought they were “too fat.” Nearly half (48%) of 15-year old girls thought they were too fat, and 25% of boys.

The report found further evidence of the harm of international focus on obesity and “healthy eating,” in high rates of young people dieting trying to lose weight, most notably girls. As the report authors noted, this behavior “has potentially serious consequences for young people’s development” and listed problems with learning, sleep, depression and anxiety, menstruation and delayed sexual maturation and nutritional deficiencies, as well as eating disorders and suicidal ideation.

Among the 15-year old girls in Scotland, 27% were engaging in risky dieting behaviors (8% of boys). [Among U.S. girls 11-15 years of age, the rate of dieting was 25%, among the highest in the world.] The report found that dieting and efforts to lose weight increased with age in all developed countries, unrelated to family affluence.

The government’s own statistics

Popular beliefs of an epidemic of childhood obesity among Scottish children proved to be a myth when the government’s own statistics, the National Study of Health and Growth study, were analyzed by public health researchers at UMDS, St. Thomas’ Campus in London. [See here for the full report and important illustrations.] Bottom line, since the 1970s, children have become healthier and better nourished — and grown taller — with weights in direct proportion to their heights. There is no epidemic of gargantuan children, as seen on TV.

When growth of children is couched in terms of BMI, it is easy to forget this includes their height and is not just a measure of their weight. (Body mass index = weight in kilograms to the square of height in meters.)

Similarly, the Social Issues Research Centre in Oxford, UK, analyzed the Health Survey for England data and found that in the past decade, there had been little change in childhood obesity rates.

Hungry for Success

The greatest disconnect in this past week’s launch of NHS Health Scotland’s new anti-obesity action plan is that it had recently released the results of its pilot program conducted since 1999 and found that, while the program was a “success” in meeting its goals, it didn’t work. [See here for the full report.]

To summarize, the blueprint for the Scottish government’s diet action plan encompassed every facet of society, including 71 actions across nine sectors. This massive initiative included every popular healthy eating idea that’s probably ever been proposed: nutritional advice was given to every household in Scotland; public health education campaigns ensued, cooking shows and resources were devoted to ‘healthy’ eating; expectant mothers were intensely targeted for education to breastfeed and improve infant and children’s diets; sustainable agriculture was employed ”to get more local produce eaten by local people;” farm shops and farmers markets grew; food labeling was expanded to increase proper choices; food producers reduced sugars, fats and salts in food products to comply with new healthier nutrient standards; dairy fats were discouraged and fish oils encouraged; supermarkets were employed to bring healthy food to low-income communities; livestock was bred to be leaner, and even sugar was to be removed from children’s medicines. Its “target of greatest importance” was to increase consumption of fruits and vegetables and complex carbohydrates.

Hungry for Success, geared towards school children, had “enormous public and political support” and was well-funded, with $126.09 million (US dollars) for its first three years alone. Healthy eating and efforts to “raise dietary awareness in schools” was made the focus, even in school health curriculums. All staff involved in health education were provided special training in nutrition and diet. Nutrition standards and diet policies were established for school meals and were monitored. According to the HMIE inspectors' report published by NHS Health Scotland, the Hungry for Success program succeeded well beyond the original recommendations.

But, its first target goal — increasing fruit and vegetable consumption in kids — proved a failure. Despite years of nonstop messaging and even giving children free fruit in school, the report found “ no evidence as yet that it directly impacts the total fruit consumption of primary school children.” It also failed to have any impact in achieving its primary goal: reducing rates of “overweight and obesity” in children.

[Those are precisely the results found in the United States, when the CDC’s 2-year study of our government’s comprehensive initiatives to promote healthy eating and physical activity were released in April. The School Nutrition Policy Initiative had also invested millions of dollars and included every proposal popularly believed needed to change diet and lifestyle behaviors and reduce childhood obesity. After 2 years, there was no change in the prevalence of obesity among the children, nor improvement in “healthy eating” and the number of fruits and vegetables the children were eating.]

So, the Scottish government’s own evidence has shown that a massively expensive and intrusive program to address a nonexistent health crisis doesn’t work. In fact, the available evidence is suggesting it is putting children’s health and well-being at risk.

But it gets worse.

Low-income assistance

As the Sunday Mail had pointed out, mums-to-be and children in low income homes are being targeted for the advice on how to eat healthier and to be given vouchers for fruits and vegetables. This is an important distinction that is rarely spoken.

As uncomfortable as it may be to admit, initiatives promoting fruits and vegetables aren’t about healthy eating. They are not about helping poor women feed their children and unborn babies with the full range of foods necessary for good nutrition and health.

They are a response to classism and prejudices that believe lower-income parents don’t know how to properly feed their children and are eating mostly junk. If they ate “right” — i.e. more fresh fruits and vegetables — they would be healthier (and thinner), so the thinking goes. Even being fat doesn’t make one immune to holding these prejudices.

The belief of low-income people eating poor diets is certainly portrayed in the images “as seen on TV,” but that doesn’t make it real.

A $6 French wheat baguette baked in an artisan brick oven is better “quality” than a $2 loaf of white sandwich bread from the day-old bakery, but nutritionally, they’re little different. That kobe beef burger with pomme frites at $175 may be “better” than a $2 fast food burger and fries, but they differ only in pedigree, not nutrition. A family can eat just as nutritionally spending $200 on private-label organic products from Whole Foods as $50 on store brand, commercial products at the corner Piggly Wiggly. Eating one 'right' way doesn't make someone a better person.

Our first question is how “quality” is defined. And do low-fat products; reduced sugar and salt foods; high fiber; and fresh produce mean a diet is automatically nutritionally healthier?

Besides the fact that the body of evidence consistently shows that fat and thin children eat no differently to explain the diversities of their sizes, income doesn’t explain the diversities of their nutritional status, either. Population dietary studies published for well over 50 years have shown low income children and families in developed countries don’t eat appreciably different, nutritionally, from higher income families. Yet, this unintuitive phenomenon continues to be restudied again and again.

Two more studies examining social-economic class and diet quality were recently published, but didn’t receive much media notice. Because they can help us question our own biases and things we think we “know” to be true — beliefs that can affect how we look and treat others — that makes them important to hear about.

Review of social class and diet

The first paper was a review of 196 published epidemiological studies examining diet quality and socioeconomic status in industrialized societies, published in the American Journal of Clinical Nutrition. A glance at the abstract might lead us to think it had found that the poor eat poorly: “A large body of epidemiologic data show that diet quality follows a socioeconomic [SES] gradient.” But, there’s that word “quality,” again.

The authors found that among the body of research, “although micronutrient intake and, hence, diet quality are affected by SES, little evidence indicates that SES affects either total energy intakes or the macronutrient composition of the diet.”

Critically reading the findings reveals that our beliefs aren’t the slam dunk we think they are.

The association found between SES and energy [calorie] intakes or the macronutrient composition of the diet intakes was either not statistically significant or inconsistent... the associations observed between SES and protein consumption were positive, negative, or not significant. No consistent SES gradient was obtained for carbohydrate intakes... No consistent SES gradient was observed for total fat intakes... The data on total energy intakes by SES were equally inconsistent...

There was no SES difference in milk consumption, but higher income brackets ate more [fat-laden] cheese. Nor was SES related to sweets consumption (higher SES groups ate more candy and pastries, lower SES groups ate more sugar and cake). The types of proteins consumed have also differed in some studies, but with little overall clinical meaning (for instance, lean meats and seafood were associated with higher SES in some studies, but more stews and canned fish with lower SES groups). In most of the studies reporting higher energy intake among lower SES, they noted, it was mostly among men, likely reflective of higher rates of physical labor.

Studies of plasma biomarkers for micronutrient vitamin and mineral status showing lower levels associated with low SES must be viewed with caution, they said: “[I]t must be noted that these studies have typically focused on nutritionally at-risk groups, namely, elderly persons and pregnant and breastfeeding women.”

Looking at fruits and vegetables, among the studies cited was an Australian dietary survey that found higher socioeconomic groups were more likely to eat more varieties of fruits and vegetables, but a closer look reveals that among the teens in this study, there was actually no difference in fruits and vegetables based on income bracket. The lowest bracket teens, for example, ate more fruit and vegetables than most of their peers in the higher brackets. Among adults, the variety of produce consumed differed among income brackets by a mere 0.2 to 0.3 fruits and vegetables.

As the review noted, a meta-analysis of studies from seven European countries found that the actual differences in consumption of produce between the highest and lowest economic groups was not clinically meaningful. Fruits differed by about 24-34 grams a day, and vegetables by about 17 grams — a tablespoon. But in other “European countries, lower SES groups consumed more vegetables and fruit, as reported in food budget surveys in Greece, Spain, and Portugal and in the Eastern European countries Poland and Hungary.”

The authors also said that the evidence doesn’t support the correctness of reports saying that lower SES groups lack nutrition knowledge, cooking skills or motivation. A number of studies, from all over the world, have shown little association with SES “and that lower income groups are more likely to cook than are higher income groups... where the middle and upper classes cook less and consume more convenience and ready-to-eat foods.” Cooking isn’t necessarily about nutritional knowledge, but also time constraints for shopping and cooking.

The authors also cautioned against attributing better health seen in higher socioeconomic populations to their diet quality, rather than the other factors associated with poverty versus wealth. “Nutrition research should not lose touch with reality,” they concluded. “Current strategies for health promotions, based on recommending high-cost foods to low-income people, may prove to be wholly ineffective.”

So, this review illustrated that social class doesn’t predict someone’s nutrition.

Low Income Diet and Nutrition Survey

This next study is particularly relevant to the government’s new healthy eating, anti-obesity initiative targeting poorer women and children. It was published by Britain's Food Standards Agency and was led by the Health Research Group at the National Centre for Social Research. The Low Income Diet and Nutrition Survey (LIDNS) specifically compared the dietary habits and nutritional status of low income families as compared to the general population across the UK, monitored by the National Diet and Nutrition Survey (NDNS) programme.

Before we get into the details of its findings, do you even remember the news coverage? It wasn’t very widely covered, but the Sunday Times concisely reported the results:

Poor eat as healthily as rich

It seems to make no difference whether you prefer pasta al dente to a chip sandwich, or guacamole to mushy peas. One of the biggest studies into eating habits of the poorest families in the UK has gone against conventional wisdom by finding their nutritional intake is similar to the rest of the country. Food experts have argued for years that the poorest families suffer from "food poverty", meaning they consume less nourishing food than the better-off and are at greater risk of long-term health problems.

But the [$11.7 million] study by Britain's Food Standards Agency (FSA), which looked at the eating habits of 3500 people, found the nutritional value of the food eaten by the poorest 15 per cent in society was little different from the average.

The study also found the rate of obesity, which has often been linked to poverty, was at a similar level among the poor as it is in the general population... the research found no direct links between a poor diet and income, nor access to shops, nor cooking skills. "The gap between the diets of people on low incomes and those of the rest of the population is not as big as some feared,"...

This was a nationally representative sampling of 3,728 of the most materially deprived households in the UK and is the most comprehensive survey of its kind. It included in-person interviews; four 24-hour dietary recalls on random days with one weekend; physical measurements taken by nurses; fasting blood collected to measure nutritional status; and extensive information on shopping habits, food storage and cooking facilities, food prep and cooking skills, access to food at school and free, eating habits, dietary supplements, medical and dental health, prescriptions, weight changes, drinking, smoking, physical activity, education, income, attitudes and barriers to health heating and food security.

The report found diets change as people grew older. Kids grow up, and their tastes and dietary habits naturally change, as has always been the case. For example, wholegrains and fruit consumption increase with age; while pizza, burgers and fries decrease.

But, between social-economic groups, while the food choices varied, the overall macro and micro nutrients were quite similar. [Click on images to enlarge.] For example, the percentages of calories consumed as carbohydrates, total fats and saturated fats were little different. And, despite popular beliefs, the low income children at every age group were consuming total calories at or below estimated requirements for their age, size and activity levels. And both the dietary assessments and blood analyses found adequate micronutrient status, with little difference between the groups:

Mean daily intakes of most vitamins and many minerals were above or close to the RNI [Reference Nutrient Intake, amount sufficient to meet the needs of about 97% of the population] in the different sex and age groups in both LIDNS and NDNS. For those where mean intakes fell below the RNI in specific age groups, this was usually the case for the same groups in both surveys.

For example, young women in both surveys (all income levels) had low daily intakes of iron, as in meat.

Average (mean and median) daily intakes of all vitamins from food sources, with the exception of vitamins A and D, were above or close to the RNI for males and females in all age groups. There was a wide distribution of vitamin A intakes; younger adults tended to have lower intakes compared with those aged 50 years and over... The main sources of vitamin A were vegetables, milk and milk products, fat spreads and meat and meat products. There was evidence of low intakes of riboflavin, particularly among older children aged 11-18 years, men aged 19-34 years and women aged 19-49 years. The main source of riboflavin, particularly amongst children, was milk and milk products.

The poorest families in the population did differ from the general population in a notable way: they suffered more food insecurity and difficulties finding enough to eat:

Just under two-fifths (39%) of the low income population reported that, in the last year, they had been worried that their food would run out before they got money for more, while a similar proportion (36%) indicated that they could not afford to eat balanced meals. Overall, 22% reported reducing or skipping meals, and 5% reported not eating for a whole day, because they did not have enough money to buy food.

Parents’ love for their children was also evidenced in this report, as parents everywhere sacrifice their diets to ensure their children are fed.

So, if we are most concerned about helping low-income families eat nutritionally, they need enough food. And the report found that the extra nutrients to address deficiencies in daily recommended intakes are best supplied by meat, fats and dairy products. Fruit and vegetable vouchers aren’t the best ways to help meet their most pressing nutritional needs for health. But these ‘healthy eating’ initiatives aren’t really about health, are they?

Reality check

So if the Scottish government isn’t following its own evidence which shows there is no crisis among its children with their health, weights or eating habits, and that their huge public health Diet Action Plan is ineffective — while diverting already limited public healthcare resources that could be being spent on healthcare — what guidelines are they going by in setting public health policies?

Maybe the Englishman called it right.

© 2008 Sandy Szwarc

* The reaction to this scheme was best expressed at Englishman’s Castle, who wrote: “It was a fucking warning, not an instruction manual you halfwitted authoritarian pokenose; I suppose Nanny will want the state of our bowel movements every morning to be added to the national database as well...” Which leads to the question: Are the weights to be recorded pre- or post-morning dump? :-)