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WESTERN ISLES FOOD AND HEALTH POLICY 

Produced by:

Healthy Islands Partnership Food and Health Group

1 August 2001

1.0  BACKGROUND

1.1   In 1992 "Scotland’s Health - A Challenge to us all" identified the need for changes to be made to the nation’s diet.

1.2  The Scottish Diet Report 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."

1.3  Since then the Scottish Diet Action Plan has been published, dietary targets for the year 2005 have been set and the Oral Health Strategy for Scotland established.

1.4  The nutritional targets and dietary guidelines set out in this document are, in the main, taken from the Scottish Diet Report and the Scottish Diet Action Plan with some local targets where evidence is available.

1.5  More recent trends have been reflected in the Scottish Health Survey (1998).  One fifth of men and women were found to be obese whilst 43% of men and 32% of women were overweight.  In total, therefore, over half of men (62%) and women (54%) were found to be either overweight or obese in Scotland.  Prevalence of any cardiovascular disorder was similar in men and women affecting approximately one in four people, and this proportion increased with age and a clear social class gradient was noted.

1.6  Eating trends in the Scottish Health Survey showed that

1.7  This updated policy identifies nutritional targets and promotes these within the context of a healthy balanced diet.

2.0  AIM

2.1  The aim of this policy is to increase awareness of the relationship between food and health and to promote the adoption of eating habits conducive to health.  It is appreciated that certain sections of a population may have poorer than average diets e.g. those on low incomes, those with mental illness or individuals with learning difficulties.  The categories may reflect lone parents, the unemployed and the elderly living alone.  The policy will reflect ways of engaging with such socially excluded groups and individuals.

3.0  OBJECTIVES

3.1  To identify food and health targets for the people of the Western Isles especially “hard to reach” and socially excluded groups.

3.2  To translate these nutritional targets into accurate and consistent dietary guidelines which can be understood and adopted by health professionals and the public.

3.3   To provide additional guidance for groups within the population who may require special consideration regarding their nutritional needs e.g. frail elderly, children under 5 years of age.  Consideration should also be given to groups within the population whose cultural and social lifestyles present a challenge to organisations.

3.4  Liaising with other agencies in promoting the link between diet and exercise.

4.0  DIET AND HEALTH

Today dietary deficiency diseases are relatively uncommon in the UK and diseases caused or exacerbated by either too much food or the wrong combination of foods are becoming increasingly common.  The relationships between diet and disease can be summarised as follows:

4.1  Energy

An individual who is maintaining weight is said to be in ‘energy balance’ i.e. his/her energy intake equals energy expenditure.

Obesity is increasing in many countries and is recognised as a major public health problem.  The details of the cause of this are uncertain but in spite of the diversity of opinions on the topic, one of the few statements that can be made with absolute certainty is that obesity can only occur when energy intake remains higher than energy expenditure, for an extended period of time.

Body Mass Index (BMI) can most easily assess obesity.  The range of BMI associated with lowest mortality risk in adults is between 20-25kg/m² .

Adults should attain and maintain a BMI between 20-25.

4.2  Carbohydrate

Available dietary carbohydrate is comprised of sugars and starches.  Sugars are a soluble form of carbohydrate characterised by sweetness.  Starches are a storage form of carbohydrate derived from plants.

Starch

Starches are complex in nature, are important sources of energy and are low in fat.  They are bound to fibre and other nutrients in their natural unrefined state.  During refining however, the fibre and several of the nutrients (e.g. iron and B vitamins) are removed.

In the diets of poor people, especially in the tropics, up to 85% of the energy may come from this source, whereas the value may be as low as 40% in the diets of the rich in many countries.

The Scottish Diet Report states that “Scotland’s nutrient target for the year 2005 is an increase in starch (complex carbohydrate) from 25% to more than 40% of total energy.

It is recommended that starch intakes be increased to at least 40% of total energy.

Sugar

Sugar is a pure substance and provides a rich source of energy in the diet.  The increase in the consumption of sugar in our national diet has greatly contributed to the incidence of obesity and dental caries.  Sugar consumption in Scotland provides 19% of dietary energy, while higher intakes have been found in pre-school children.

There is extensive evidence that sugars are the most important dietary factor in the cause of dental caries.  Both the total amount of sugar consumed and the frequency of consumption are important factors.  The consumption of sugar particularly in the form of confectionery, snacks and soft drinks should therefore be reduced, especially between meals.

There is substantial evidence that indicates all types of sugar can promote decay to varying extents.  Milk contains sugar in the form of lactose.  It has a comparatively low potential to cause decay and this is usually offset by the influence of other nutrients found in milk.  Consequently, dental experts regard milk as non-cariogenic.  Also, there is no evidence that sugars occurring naturally in fruit and vegetables have adverse effects on health.

It is recommended that in children, intakes of NME (Non-Milk-Extrinsic) sugars be reduced to less than 10% of dietary energy.

It is recommended that there is no increase in intake of NME sugars in adults and that the average intake should not exceed 60g/day or 10% of total dietary energy.

4.3  Dietary fibre

Fibre is a form of carbohydrate found in foods of plant origin and is present in wholegrain cereal and their products, fruit and vegetables and pulses such as lentils, peas and baked beans.  A lack of dietary fibre has been associated with a wide range of diseases including constipation, diverticular disease, haemorrhoids, cancer of the colon and other large bowel disorders.

It would therefore seem reasonable for the population to be consuming sufficient quantities of dietary fibre.  However, current levels in Scotland are estimated at 10g/day.

It is recommended that adults should have an intake of fibre, as Non-Starch-Polysaccharide (NSP), of at least 16g/day.

4.4  Protein

Protein generally comprises 10-15% of dietary energy, but it has more significance than simply as a source of energy.  It is the major functional and structural component of all the cells of the body and is essential to maintain cell integrity and function, and for health and reproduction.

Recent studies have shown that protein intakes in Scotland are about 79g/day for males and 61g/day for females – these figures representing about 15% total energy.

Most of this protein is from animal sources with a relatively small amount from vegetable sources.  An increased use of vegetable protein together with a corresponding reduction in the use of animal protein sources would help to reduce fat intakes and increase intakes of NSP.

It is recommended that greater use should be made of vegetable protein sources with no increase in protein intake.

4.5   Fat

Fats are important components of all diets for:

Deaths from coronary heart disease (CHD) in Scotland are amongst the highest in the world and it is the major cause of death in males and females under the age of 65.

It is recommended that total fat intake should provide less than 35% of total energy intake daily, with saturated fat contributing a maximum of 10-15%.  However, current intake in Scotland is estimated at 44% and saturated fat intake at 17%.

Evidence has shown that there is a relationship between a high fat consumption, particularly saturated fat and trans fatty acids, and the development of CHD.  Studies have also shown that there is an inverse relationship between the development of this disease and the consumption of poly- and mono-unsaturated fat.

It is recommended that total fat intakes should be reduced to 35% of total energy.  Of this, less than 11% should come from saturated fat and less than 2% from trans fatty acid sources.  Monounsaturates should contribute less than 13% of the total fat.  Polyunsaturated should contribute less than 10% of total fat.  (Of this, more than 1% should come from oily fish e.g. mackerel and sardines).

4.6   Salt

The main source of dietary sodium is common salt.  Various studies have shown the relationship between a high salt intake and elevated blood pressure, which can in turn exacerbate renal, cerebrovascular and cardiovascular complications.

The Dietary Survey of British Adults (1990) found total salt intakes to be in the range of 4-18g salt per day in males and 3-14g in females.  This intake is made up of 15-20% discretionary salt

(i.e. added in the home), 15% natural unprocessed foods (e.g. eggs) and 60-70% manufactured products (e.g. pickles, crisps, tomato ketchup, canned products).

Since salt is habit forming and largely an acquired taste, it is recommended that the amount of salt added during cooking and at the table should be reduced along with a decreased consumption of manufactured products.

These products should be replaced with fresh foods where possible and the Western Isles should continue to support the national initiative by the Scottish Diet Report to reduce the addition of salt during processing.

It is recommended that salt intakes be reduced by 6g a day by:

4.7  Alcohol

Alcohol consumption in the UK has risen steadily during the last 50 years and at present contributes about 7% of our total energy intake.

Since alcohol is a non-essential nutrient a reduction to 4% of total energy or 2-3 units of alcohol/day is recommended.

It is recommended that we continue to use safe alcohol limits of 14-21 units/week for females and 21-28 units/week for males’ i.e. a maximum of 2-3 units per day for females and 3-4 units per day for males.

5.0  NUTRITIONAL RECOMMENDATIONS

These nutritional recommendations are identified in ‘Eating for Health’ - A Diet Action Plan for Scotland (1996), The Scottish Diet (1993) and The Manual of Dietetic Practice (1994).

6.0  DIETARY GUIDELINES

If the nutritional targets are to be achieved then simplified dietary guidelines must be given which can be easily interpreted.

7.0  MONITORING AND EVALUATION

7.1   Monitoring is required in order to assess the progress in reaching the recommended nutrient and dietary targets for the Western Isles as set out in Section 5.  The Health Survey for Scotland published annually will enable trends to be assessed, particularly in relation to cardiovascular disease.

7.2   Monitoring will also necessitate each agency devising their own individual procedures for adoption and implementation.

Appendix 1

SPECIAL GROUPS IN THE POPULATION

1.   Infants

Weaning is the process of expanding the diet to include foods and drinks other than breastmilk or infant formulae.  From around 4 months of age an infant’s nutritional needs cannot be met by milk alone.  This process should be a gradual one and the diet should offer a variety of tastes and textures based on family foods.  Encouragement should be given to reducing consumption and frequency of high sugar containing food and drinks. 

The majority of infants should not be given solid food before the age of four months.  First foods should be those of low allerginicity.  Suitable first foods are fruit such as banana, pear, apple and vegetables such as potato, carrot and swede.  Non-gluten containing cereals (e.g. baby rice, ground rice) may also be given.  Cow’s milk products (e.g. plain unsweetened yoghurt, unsweetened custard) may be given from 4 months.  Rusks are not suitable as a first weaning food.  A mixed diet should be offered by six months.

Infants should begin to be offered soft lumps in order to promote chewing skills between the age of 6 to 9 months.  There should be a gradual progression from soft lumps to mashed foods.  Gluten-containing cereals may be given.  These include: wheat, wheat flour, oats, rye and barley.  Whole cow’s milk may be used in cooking but should not be given as the main drinking milk before 12 months of age.

Finger foods, such as toast, bread, cheese or fruit and vegetables, should be given to encourage food handling and chewing.  Most varieties of rusk contain a significant amount of sugar and are not recommended.

At the age of 9-12 months it is important to establish a dietary pattern of 3 meals per day with additional nutritious snacks encouraged.  Foods should be minced or finely chopped and foods from each of the four food groups (Meat and alternatives, bread and cereals, fruit and vegetables, milk and milk products) should be offered to ensure an adequate intake of all nutrients.

2.   Young Children (under 5)

The pre-school child is almost totally dependent on others for his or her food.  Parents, and other carers, should realise that their own eating habits, likes and dislikes, will be the ones the child imitates.

Current healthy eating guidelines for adults should not be applied to this population group.  Many children under five have small appetites and it is often necessary to include foods which are nutrient dense in order to meet their nutritional requirements.  Healthy eating advice can be directed at the whole family but the special nutritional needs of the young child must be borne in mind.

3.   Young People (Adolescents / Young Adults)

This is a period of rapid growth and development.  It is also the time when young people want to express their independence and a time when peer group pressure is strong.

Making decisions about food choice is often one of the first ways in which a young person will exert their independence.  Tact, patience and understanding are required in large measures both by parents and by health professional advisers to steer the adolescent towards sensible healthy eating and away from extreme diets with potentially harmful consequences.

Long term effects or threats of future poor health rarely influence young people.  The healthy eating message must therefore be a positive one, capitalising on their desire to get the most out of life when they are young.

4.   Preconception and Pregnancy

Specific nutritional guidance is essential for both mother and child.

5.   Elderly

Nutrition is no less significant to the elderly than it is to the younger person.  It is recommended that the majority of people aged 65 years and over should adopt where possible similar patterns of eating and lifestyle to those advised for maintaining health in younger adults.

However achieving and maintaining a good nutritional status can be more problematic for the older adult as a variety of physical, mental, social and economic factors can pose serious obstacles.  In these situations it may be more appropriate to recommend a diet which includes nutrient dense foods. (See Nutritionally Vulnerable.)

6.   Nutritionally Vulnerable

This group includes people of all ages from the young to the frail elderly.  Many of these people are acutely ill, suffering from a chronic condition or disability or they may have special needs.  Whether they live at home, in residential care or in hospital, maintaining an adequate nutritional intake is fundamental to their care.  Depending on the individual, it may be necessary to include nutrient dense foods ( e.g. full cream milk ) in order to achieve an appropriate nutritional intake. Assessment of nutritional status should be carried out routinely on admission and at monthly intervals using an appropriate and validated nutritional screening tool.  This is an area that needs individual guidance by a dietitian.

7.   Therapeutic Diets

People who require a therapeutic diet should see a dietitian to ensure their specific dietary needs are met.

8.   Groups Requiring Additional Nutritional Information

Individuals with specific dietary beliefs, e.g. vegetarians and vegans, also require consideration to ensure nutritional adequacy that is consistent with current advice.

9.   Low Income Groups

It is possible to eat healthily within the limits of a low income and achieve the current healthy eating targets.  Low income groups are not homogenous and consequently approaches to the promotion of healthier diets must vary.  It is important to recognise that affordability and availability issues are paramount as well as lack of cooking skills.  In addition, cultural reasons may operate against behavioural change.  It is important that educational approaches are used that focus on the knowledge skills and attitudes of participants and that support is offered throughout the change process.

10. Ethnic Minorities

Ethnic minority groups represent a certain percentage of the population in the Western Isles.  Eating patterns can be influenced by:

It is important that different dietary habits are recognised and considered within the nutritional targets.  Health professionals need to acquire sound knowledge and understanding of the diet, religious beliefs, cultural habits, lifestyle and attitudes in order to ensure that dietary instruction fits in with traditional customs and eating habits. 

Appendix 2

HEALTHY ISLANDS PARTNERSHIP FOOD AND HEALTH GROUP

The first local Food and Health Policy was produced in 1992 by the Western Isles Food and Health Group.  Additional scientific evidence has now resulted in a need to update the policy.

In 1996, the Food and Health Group came under the umbrella of the Healthy Islands Partnership and became known as the Healthy Islands Partnership Food and Health Group.  This is an interagency group and has representatives from local authority, health board, further education and the local enterprise company.  The present membership is as follows:

REFERENCES

Department of Health.  The nutrition of elderly people.  Report on health and social subjects No 43. London: HMSO, 1992

Scottish Office Department of Health.  Scotland’s health a challenge to us all.  The Scottish Diet.  Edinburgh: HMSO, (1993)

Scottish Office Department of Health.  Scotland’s health a challenge to us all.  Eating for health – A diet action plan for Scotland.  Edinburgh: HMSO, (1996)

Thomas B.  Manual of Dietetic Practice,  Blackwell Scientific Publications.  (1994)