Less oils and fats in food preparation and in spreads; preference to
be given to liquid vegetable oils.
Correspondingly, the report recommends that everybody will do well to eat
less fatty meat, fewer high-fat dairy products, fewer 'commercially baked
products', and less alcohol. As its title indicates, the report is not only
concerned with diet, and makes many other recommendations to prevent cardiovascular
disease. But its emphasis on diet is impressive, and throughout the 1980s
'Prevention of Coronary Heart Disease' probably became the most influential
document on its subject - certainly in those countries not already plentifully
supplied with expert reports.
Cancer and heart disease: consistent messages The eventual 'Consensus
Statement' on diet and cancer is similar to and consistent with the emerged
scientific consensus on diet and heart disease. The recommendations of the
ECP/IUNS group to the general public are:
Decrease the intake of saturated and unsaturated fat in countries where,
on average, fat constitutes more than 30 per cent of total food energy (calories).
In other countries, people should maintain their lower fat intake. Consumption
of fat can be decreased (a) by lowering the intake of butter, margarine,
cooking oil, salad oils, and dressings; (1)) by selecting fish, poultry,
leaner meat products, and low-fat dairy products; and (c) by broiling, baking,
and steaming foods, rather than frying.
Eat a varied diet that contains different types of vegetables and fruits,
especially green leafy and root vegetables and citrus fruits; these foods
can supply an adequate intake of vitamins and minerals, so that supplements
do not have to be used.
Consume foods that are rich in complex carbohydrates (e.g. starch and fibre)
that are known to promote healthy bowel function.
Maintain appropriate body weight. If a lower energy intake is desirable,
eat foods with complex carbohydrates, including whole-grain cereal products,
fruits, and vegetables, instead of the higher-energy fatty foods.
Consume a low-salt diet. A desirable goal is less than 5g of salt per day
as recommended in relation to cardiovascular diseases.
Use fresh or minimally processed foods rather than cured, pickled, or traditionally
smoked foods. Do not eat mouldy foods.
Drink alcohol in moderation, if at all.
Industry and government are urged to collaborate in the creation of European
food supplies that should lower national and international rates of illness
and death from cancers.
Presenting the findings of the Aarhus workshop at the International Congress
of Nutrition held at Brighton in August 1985, before their official publication,
Professor Kenneth Carroll of the University of Western Ontario, one of the
workshop leaders, commented: 'If you eat food in its natural state without
processing, you get a natural balance of nourishment'.215
Health for all in Europe?
The most scientifically penetrating expert report reviewed so far is 'Healthy
Nutrition', commissioned by the World Health Organisation Regional Office
for Europe and published in 1988.216
This book is a clear challenge to all governments; to European farmers;
to the European food processing industry; to restaurants, cafeterias, and
fast-food chains; to health personnel, teachers, dieticians and cooks; and
ultimately, for anyone among Europe's 850 million people cooking a meal!
wrote Jo Asvall, WHO European Regional Director, in his foreword to this
150-page hook. Superficially, despite its clear title and attractive cover
with a colour photograph of a three- generation Italian family enjoying
an open-air lunch, 'Healthy Nutrition' is unexciting, a dull report, stuffed
with statistics and written in an oblique style. Like any new map, it takes
some studying. What it amounts to is a blueprint for use by the architects
of new, rational and progressive food and agriculture policies designed
for the countries of the WHO European region.
'Healthy Nutrition' is written by Professor Philip James (of the NACNE report)
in collaboration with three European colleagues: Professor Anna Ferro-Luzzi
from Italy, Professor Wictor Szostak from Poland, and Professor Bjorn Isaksson
from Sweden. The report was drafted in 1985 and 1986; successive drafts
were circulated to colleagues throughout Europe; and the final report is
a synthesis of comments received. Like the NACNE report, 'Healthy Nutrition',
sometimes known as 'EuroNACNE', is largely a report on reports:
The recommendations presented and views expressed reflect, whenever
possible, those of government or other official reports; an attempt has
been made to integrate the views of different national expert committees
so that the final outcome represents as large a consensus as possible.
In its 'Executive Summary', the report sets out the problem and proposes
a solution. In doing so the scale of its vision immediately becomes apparent:
In Europe as a whole, about half the premature deaths in men and women
below the age of 65 years result from diseases to which diet makes an important
contribution. Coronary hear disease, stroke, many kinds of cancer, oral
disease, anaemia, goitre, cirrhosis of the liver diabetes, gallstones, obesity,
high blood pressure and bone disease in the elderly have a huge effect on
medical services. These conditions should be considered preventable, even
if the precise way in which dietary deficiencies or excesses lead to them
remains obscure. As analysis of the dietary factors involved suggests that
a common set of nutrient goals can b( developed as desirable national health
goals for the people of Europe.
This is a public health statement of the utmost importance. It says in effect
that there is a vast amount of suffering and premature death in Europe,
from diseases of which the typical European diet is a contributory cause;
and that the problem is so vast that we simply cannot wait until all the
scientific answers are in before acting. By the time scientists know the
exact cause of the diseases that most of us now suffer and die from, we
ourselves will no doubt all be dead.
The agreement between 'The Surgeon General's Report on Nutrition and Health',
and 'Diet and Health' is generally also striking. The main difference, is
that the official Surgeon General's report stops short of specifying targets
for a healthy diet, and was for this reason criticised as 'wishy-washy'
by Michael Jacobson of the Centre for Science in the Public Interest. The
summary recommendations of the two reports compare as follows.
On fats and cholesterol:
Reduce consumption of fat (especially saturated fat) and cholesterol.
Choose foods relatively low in these substances, such as vegetables, fruits,
whole grain foods, fish, poultry, lean meats, and low-fat dairy products.
Use food preparation methods that add little or no fat. [Surgeon General].
Reduce total fat intake to 30 per cent or less of calories. Reduce saturated
fatty acid intake to less than 10 per cent of calories, and the intake of
cholesterol to less than 3OOmg daily. The intake of fat and cholesterol
can be reduced by substituting fish, poultry without skin, lean meats, and
low- or non-fat dairy products for fatty meats and whole-milk dairy products;
by choosing more vegetables, fruits, cereals and legumes; and by limiting
oils, fats, egg yolks, and fried and other fatty foods. [National Academy].
On complex carbohydrates and fibre:
Increase consumption of whole grain foods and cereal products, vegetables
(including dried beans and peas), and fruits. [Surgeon General]. Every day
eat five or more servings of a combination of vegetables and fruits, especially
green and yellow vegetables and citrus fruits. Also, increase intake of
starches and other complex carbohydrates by eating six or more daily servings
of a combination of breads, cereals, and legumes. [National Academy].
Reduce intake of sodium by choosing foods relatively low in sodium
and limiting the amount of salt added in food preparation and at the table.
[Surgeon General]. Limit daily intake of salt (sodium chloride) to 6 grams
or less. Limit the use of salt in cooking and avoid adding it to food at
the table. Salty, highly processed salty, salt-preserved, and salt-pickled
foods should be consumed sparingly. [National Academy].
To reduce the risk for chronic disease, take alcohol only in moderation
(no more than two drinks a day), if at all. Avoid drinking any alcohol before
or during driving, operating machinery, taking medications, or engaging
in any other activity requiring judgement. Avoid drinking alcohol while
pregnant [Surgeon General]. The committee does not recommend alcohol consumption.
For those who drink alcoholic beverages, the committee recommends limiting
consumption to the equivalent of less than 1 ounce of pure alcohol in a
single day. This is the equivalent of two cans of beer, two small glasses
of wine, or two average cocktails. Pregnant women should avoid alcoholic
beverages. [National Academy].
On weight control:
Achieve and maintain a desirable body weight. To do so, choose a dietary
pattern in which energy (caloric) intake is consistent with energy expenditure.
To reduce energy intake, limit consumption of foods relatively high in calories,
fats, and sugars, and minimise alcoholic consumption. Increase energy expenditure
through regular and sustained physical activity. [Surgeon General]. Balance
food intake and physical activity to maintain appropriate body weight. [National
Academy; the report adds that its recommended diet includes 'moderately
low levels of fat' and also 'only low levels of added sugars'].
Both reports also recommend reduced sugar consumption, to avoid tooth decay;
and a diet rich in calcium, especially for women. The Surgeon General's
report recommends iron-rich foods for children, adolescents, and women of
child-bearing age, provided that the sources of iron (and also calcium)
are low in fat. The National Academy report acknowledges that many people
take vitamins and/or minerals in pill form, and cautions against doses in
excess of the RDA (recommended Dietary Allowance).
Positive messages The main recommendations of both reports are generally
harmonious not only with each other but also with those of almost all expert
reports on diet and health published since the 1970s and reviewed here.
Within this harmony there is a significant shift in emphasis. Reports published
in the late 1980s are much more inclined to emphasise the positive value
of nourishing foods, especially vegetables, fruits, and wholegrain cereals,
together with lean meat, fish, and low-fat dairy products: while they repeat
the standard recommendation to consume less fat, saturated fat, sugar, salt
and alcohol, the stress is positive, on healthy foods, rather than negative,
on unhealthy nutrients.
There are a number of reasons for this shift. First, market research and
common sense has encouraged expert committees to give positive rather than
negative advice. Second, a consumer can literally grasp a cabbage, an orange,
or a loaf, but does not have a feeling for (say) saturated fatty acids.
Third, the message to eat more healthy foods rather than less unhealthy
foods is helpful to many sections of industry and therefore also to government.
Fourth, a mass of scientific evidence accumulated since the 1970s has identified
the positive value of vegetables, fruit and wholegrain bread and cereals;
in particular, these whole foods are rich in a combination of nutrients
collectively known as 'anti-oxidants' that probably protect against cancers
and also against heart disease.
One relatively new theme emerges in 'Diet and Health': the evidence that
protein of animal origin, in the quantity it is typically consumed in the
USA and many other Western countries, is too much of a good thing. At least
by implication, virtually all expert reports published before the late 198Os
assume that protein is not a public health issue; as long as around 10 per
cent of total calories is in the form of protein people will be well nourished,
and anything above that figure is no problem, is the impression given. However,
another mass of scientific evidence now strongly suggests that a diet high
in animal protein increases the risk of cancers and heart disease. In practice,
a diet high in animal protein is likely to be high in saturated fat; a diet
low in animal fat will tend to be lower in animal protein. However, the
National Academy cautions against any enthusiastic substitution of lean
for fatty meat; indeed, it recommends that people generally should eat less
Because there are no known benefits and possibly some risks in consuming
diets with a high animal protein content, the Committee recommends that
protein intake not be increased to compensate for the caloric loss that
would result from the recommended reduction in fat intake_ The Committee
does not recommend against eating meat; rather, it recommends consuming
lean meat in smaller and fewer portions than is customary in the United
The importance of both reports and their recommendations was summarised
by Dr Michael McGinnis in a paper published in 1989 in the American Journal
of Clinical Nutrition. Dr McGinnis, Chairman of the Nutrition Policy Board
of the US Government Public Health Service responsible for the Surgeon General's
report, was also an ex-officio member of the National Academy's Food and
As he points Out, the Surgeon General's report states that of the ten leading
causes of death in the US, five (atherosclerosis, coronary heart disease,
stroke, diabetes, and some types of cancer) are evidently caused at least
in part by the typical American diet; and another three (liver cirrhosis,
accidents, and suicide) are partly caused by excess drinking of alcohol.
'Although the precise proportion attributable to diet is uncertain, the
eight conditions account for nearly 1.5 million of the 2.1 million total
deaths in 1981'. Developing this theme, Dr McGinnis states:
Dietary excesses and imbalances also contribute to conditions such as high
blood pressure, obesity, dental diseases, osteoporosis, and gastrointestinal
diseases that inflict a substantial burden of illness on society ... Illness
and deaths from coronary heart disease alone cost Americans an estimated
$49 billion in direct health-care costs and lost productivity in 1985, and
the costs of cancer for that year were estimated at $72 billion.
And the general conclusion, endorsed by the US Department of Health and
Human Services, is:
A reduction in intake of foods containing fat accompanied by an increase
in foods containing complex carbohydrates and fibre should reduce risk not
only for coronary heart disease but also for certain types of cancers, stroke,
diabetes, and, perhaps, some gastrointestinal conditions. The report further
emphasises that its recommendations can readily be accomplished by an overall
increase in dietary intake of vegetables, fruit, beans, and grains and a
choice of lean meats, poultry without skin, fish, and low-fat dairy foods.
The politics of change
Complete government support for a national food and nutrition policy requires
backing from the departments responsible not only for health, but also for
agriculture and the food industry. In the USA, the UK and other countries,
the department of health can set new agendas; but the department of agriculture
has influence over the national food supply, and therefore decides whether
or not any agenda will be put into practice.
Prevention begins in childhood
Are dietary guidelines designed for everybody, or only for adults? What
about children? Throughout the twentieth century, paediatricians, the physicians
responsible for child health, together with the nutritionists and dieticians
who work with children, have said that growing children need lots of energy
(calories) from food, as well as protein; and have encouraged parents to
feed their children with a so-called 'energy-dense' diet, meaning in practice,
foods containing a lot of fat and added sugar.9 Go for growth! By the 1980s
it was generally accepted that the right diet for children over the age
of 5 is the same as that for adults; but many paediatric health workers
refused to accept that the scientific consensus applies to young children
under the age of 5. 144
In contrast, physicians and health workers concerned to prevent Western
diseases are increasingly sure that after weaning, children should eat much
the same diet as adults. People rarely actually suffer from heart disease
Until middle age; but the process that eventually leads to a heart attack
begins at the beginning of life, for anybody who eats a typical Western
diet. By the time heart disease is measurable or evident, it is often too
late to make much difference. Increasingly, therefore, the focus on prevention
of heart attacks has shifted from middle age to childhood.
In 1983 the American Heart Association stated that its recommendations for
adults apply to all healthy children over the age of 2. In 1986 the American
Academy of Pediatrics, in a short report, 'Prudent Life-style for Children:
Dietary Fat and Cholesterol', did not agree. Commenting on the view
that children should eat a low-fat diet, the Academy said, for children
of all ages:
Meat and dairy products, which would be restricted, form an important
source of protein; dairy products provide 60 per cent of dietary calcium;
and meat is the best source of available iron... Current dietary trends
in the United States - decreased consumption of saturated fats, cholesterol,
and salt and an increased intake of polyunsaturated fats - should be followed
with moderation. The optimal fat intake cannot be determined, but 30 to
40 per cent of calories seems sensible for adequate growth and development.
British children: a radical re-think
In 1988 the UK Department of Health published a new version of its 'Present
Day Practice in Infant Feeding'252 prepared by its Panel on Child Nutrition
of the Committee on Medical Aspects of Food Policy. This report is the beginning
of a new age for parents of young children, and for health professionals
concerned with children; for it radically revises the old thinking, as published
eight years previously in the first edition of 'Present Day Practice in
Infant Feeding'.253 Effectively, the 1988 edition states that once babies
are weaned, their diets should have the same nutritional quality as recommended
in the UK for adults in the 1984 COMA report on 'Diet and Cardiovascular
Weaning and the diets of young children. The change from the diet of
the young infant to one in which only 35 per cent of food energy should
be derived from fat with a contribution of only 15 per cent from saturated
fatty acids, and in which fibre-rich foods containing complex carbohydrates
are preferred to simple sugars, is an important aspect of the weaning process.
Undesirable styles of eating and drinking should be discouraged, and feeding
practices should foster the adoption of healthy dietary habits ... Children
who habitually consume large quantities of milk and dairy products, fried
foods, fatty meats and manufactured foods with a high fat content are almost
certain to exceed the recommended amounts of total dietary fat and of saturated
In 1984 the COMA report on 'Diet and Cardiovascular Disease' carried a warning,
stating that its recommendation that consumption of total fats be cut to
a maximum of 31-35 per cent of total calories and of saturated fats to a
maximum of 15 per cent of total calories, applied only over the age of 5.
New evidence convinced the 1988 COMA panel on Child Nutrition that children
over the age of 2 should eat a lower fat diet, just like older children
The substitution of whole cow milk by lower fat milk is not recommended
for children under the age of 2 years. For children above this age, semi-skimmed
milk and other reduced-fat dairy products may be introduced into the diet
... We note the inclusion, without reported harmful effects, of semi-skimmed
milk in the diets of two year old children surveyed in Sweden and in Canada,
and we are aware that this practice is not unknown in Britain. We endorse
the recommendations in 'Diet and Cardiovascular Disease', but we consider
that in the light of currently available evidence it is reasonable to introduce
semi-skimmed milk into the diet of children between the ages of 2 and 5
years provided that the diet as a whole is adequate.
In addition, 'Present Day Practice in Infant Feeding' recommends a low-sugar,
low-salt diet for all babies and young children as part of the weaning process,
Immediately following this official COMA report, the Coronary Prevention
Group, the UK equivalent of the American Heart Association, published 'Children
at Risk: Should Prevention of Coronary Heart Disease Begin in Childhood?'.
The answer to the question posed in the title of this 12-page statement,
is an unequivocal 'yes'.
The Coronary Prevention Group report is concerned with children of all ages.
It pointed to the fact that the diets of British schoolchildren are known
to be unhealthy. A survey of over 3,000 British 11 and 14 year-olds commissioned
by the Department of Health, undertaken in 1983 and initially published
in 1986, had shown that around a quarter of British schoolchildren consume
more than 40 per cent of their calories in the form of fats. Commenting
on this for a special Granada Television World in Action programme, 'The
Threatened Generation', Professor Philip James stated:
This type of diet is precisely what one would expect from a country
with the highest risk of heart disease in the world, and clearly the type
of diet they are getting at school is even worse than the food they are
getting at home ... I think if the children continue to eat the same sort
of food, we can pretty confidently predict that we will continue in Britain
to have the highest heart disease rate in the world. Indeed one might predict
that the heart attack rate will go up.
The Coronary Prevention Group endorsed the recommendations of the COMA panel
on Child Nutrition, and went further, recommending skimmed as well as semi-skimmed
milk for children between the ages of 2 and 5. Furthermore:
Saturated fat is also consumed in other dairy foods, meat and meat products,
cakes and biscuits etc., and substitution of low-fat foods for these will
also be necessary. Reduction in children's fat intake should not be equated
with removal of dairy tat from the diet.
The final recommendations of the Coronary Prevention Group include a call
for a 'national health strategy for children' to be developed by the UK
Department of Health together with the Department of Education and Science;
'detailed, quantified and practical dietary guidelines' for children under
5 to be devised by the Department of Health COMA panel on Child Nutrition;
revival of nutritional standards for schools catering; and major anti-smoking
and pro-exercise campaigns directed at schoolchildren. The recommendations
for the diets of children over the age of 2 is much the same as that of
the 1988 'Present Day Practice in Infant Feeding':
There should be a progressive reduction of fat in children's diets,
beginning from the age of two years and reaching the levels recommended
for adults by five years. This will involve the introduction of low-fat
milk, but with proper attention to calorie and vitamin intake. The energy
deficit created by the reduction in saturated fat should be made up with
complex carbohydrates. Intake of sugar and salt should be restricted.
A bold Scottish line
After Northern Ireland, Scotland also took a line on the prevention of heart
disease bolder than the policy laid down in Whitehall.
In 1979 the Scottish Home and Health Department commissioned a report from
an expert committee chaired by Professor Ian Bouchier. This agreed that
rates of death from coronary heart disease in Scotland are 'appalling',
noted that excessive drinking of alcohol is a major public health problem
in Scotland, recorded that the Scots on average consume less than half the
amount of green vegetables eaten in the UK, but did not accept that action
was needed to change the Scottish diet:
Dogmatic assertions about diet have done much to confuse the profession
and the community. The relationship of various dietary factors to ischaemic
heart disease has been the subject of intense interest and research over
a world-wide scale for many years. Despite this enormous effort, no conclusive
evidence exists so far which shows that a particular dietary factor is associated
with the initial arterial lesion or any subsequent thrombotic event which
leads to ischaemic heart disease.
The committee, mostly made up of academics, concluded that more research
was needed. In 1988 the Home and Health Department set up a 'Working Group
on Prevention and Health Promotion' chaired by a general practitioner, Dr
Keith Davidson, mostly made up of community health workers. Their report,
'Prevention of Coronary Heart Disease in Scotland', was endorsed by Michael
Forsyth, then junior Minister at the Scottish Office responsible for public
health, and published with official status in April 1990.
Referring to the 1984 COMA report, the NACNE report, and the 1988 WHO report
for Europe, 'Healthy Nutrition',216 the section on 'Nutrition' begins:
Nutrition policies have been developed by various scientific expert
committees for the prevention of cardiovascular disease and for the wider
prevention of non-communicable diseases. A recent review of such developments
throughout European countries has shown a remarkable uniformity in the content
of national food and nutrition policies... Such evidence as is available
[in Scotland] indicates that dietary habits fall short of these generally
recommended, particularly in respect of a low intake of fruit, vegetables
and wholegrain cereals, and excess fat and salt intake. Because of the crucial
role which nutrition plays in shaping the health of a population, and because
of its impact not only on heart disease but on a wide variety of chronic
diseases ranging from dental caries to bowel cancer, it is clear that some
action is now called for, both at national and local levels.
The report notes that even a 10 per cent reduction in cardiovascular diseases
in Scotland would save stlg60 million a year in costs to the taxpayer for
the National Health Service, and in output lost through certified incapacity
to work. The savings of a 50 per cent reduction, as achieved in the USA
and Australia, would be stlg300 million a year (1988-89 prices).
A comprehensive set of recommendations for action are included in the report;
a 'population strategy' is proposed, and 'detailed guidelines on nutrition,
based on recent reports, should be prepared nationally and locally for each
area health board'. The report ends with 'A framework for a national major
reports': by this it means not only the officially recognised 1984 COMA
report, but also the NACNE report and the 1988 WHO report for Europe, unrecognised
And the guidelines finish with recommendations that 'energy intake be maintained',
because everybody should be more physically active; and that vitamin and
mineral intakes should be those officially recommended in the UK.
- Total fat intake in the population as a mean should be reduced to 35
per cent of energy ig the long term goal.
- Saturated fat intake in the population should be reduced to 15 per cent
of total energy mt being the long term goal.
- Polyunsaturated fatty acid intake in the population should be increased
to 5 per cent 0 total energy intake.
- The polyunsaturated/ saturated ratio (P/S) should be increased to 0.32
with 0.45 being the long term goal.
- Intake of sugar should be not more than 12 per cent of total energy
- Fibre intake daily should be increased to 25 grams and to 30 grams in
the long term.
- Salt intake should be decreased as it is considered to be needlessly
high. The reductior should be by 1 gram per day, and by 3 grams per day
in the long term.
- Alcohol intake should be reduced to 5 per cent of total energy intake
and to 4 per ceni in the long term ...
- No change is recommended in the level of protein intake but some shift
from animal to cereal and vegetable protein is recommended.
- Intake of carbohydrate should increase to compensate for the reduction
in fat intake. This should be in the form of fruit, vegetables, bread and
These guidelines for Scotland are a departure from Whitehall policy of the
day. Insofar as they follow the 1984 COMA report, they acknowledge that
everybody in Scotland is at high risk of coronary heart disease. And they
accept the NACNE report's targets (short4erm, or long4erm) for consumption
of sugar, salt, and fibre, while going further than NACNE for alcohol. The
recommendation to switch from animal to cereal and vegetable protein acknowledges
the mounting evidence showing that the old idea that animal protein is superior,
has turned out to be mistaken.
Britain: a new COMA
At the end of 1986, the Department of Health set up another new COMA panel,
on RDAs, or 'Recommended Daily Amounts'. Since the 1940s, as already mentioned,
the governments of the UK, the USA, and then eventually of countries all
round the world, have set official recommended levels (PDAs) for energy
(calories), protein, and those vitamins and minerals reckoned to be important
for public health. The purpose of such guidelines is to ensure a food supply
that includes levels of these nutrients judged to be more than enough to
avoid deficiency diseases.
With rare and then only partial exceptions, RDA reports are not concerned
with fat, carbohydrate (starch and sugar), fibre, salt, or alcohol. This
is because when the need for vitamins and minerals was first identified,
after the discovery of the vital importance of vitamins A, B, C and D as
well as of the minerals calcium and iron, over-consumption was not a public
health issue. Fat and carbohydrate were not seen as problems, as long as
people ate enough; salt (or rather sodium, one part of salt) was identified
as a mineral in plentiful supply for which an RDA was therefore not needed;
fibre was not known to be relevant to human health; and alcohol was off
the agenda, being consumed not as food but as drink.
For example, the 1979 UK RDA report,121 in currency throughout the 1980s,
produced by a COMA panel and accepted as an official document by government,
makes no reference to the possibility that people may eat too much fat or
sugar, except to say:
If intakes of fat are not to provide an unduly large proportion of the
total food energy, at least half of the energy should be derived from carbohydrate.
Most of this should be in the form of starch, which is normally associated
with other useful nutrients.
Instead, detailed tabulated recommended figures for energy (calories), protein,
and some vitamins and minerals, are set out. Thus, the 1979 UK COMA RDA
report specifies (taking an example at random) that girls aged 7-8 should
consume 1 .Omg of riboflavin (vitamin B2) every day; and this figure rises
to 1.2mg aged 9-11, l.4mg aged 12-14 , and 1.7mg aged 15- 17, falling to
1.3mg for adult women.
So the seeker after dietary guidance in the UK and in most other Western
countries has been faced with two completely different types of advice.
The first - dietary guidelines - make recommendations about the consumption
of fat, saturated fat, sugar, salt, fibre, alcohol, other nutrients, and
sometimes also types of food, in broad outline, and are designed to prevent
diseases of excess or imbalance. The second - RDAs - specify requirements
for energy (calories), protein, and various vitamins and minerals in minute
detail, and are designed to protect against diseases of deficiency. It is
no wonder hat consumers are confused, not only by conflicting advertisements
produced by the food industry, but also by advice promulgated by government.
Meat, cheese, eggs and milk, for example, are evidently healthy foods, judged
in the context of RDAs: they contain plenty of protein and various vitamins
and minerals. But dietary guidelines reports, first published just a generation
after the first RDA reports, point out that meat, milk and dairy products
are major sources of fat and of saturated at in the Western diet, and therefore
are unhealthy foods unless eaten sparingly.
Some enlightenment is given by the UK COMA RDA report originally commissioned
in late 1986, which was eventually published in July 1991 with the unexciting
title 'Dietary Reference Values for rood Energy and Nutrients for the
United Kingdom'. Following the US National Academy of sciences report
on 'Recommended Dietary Allowances' published eleven years previously in
1980, his is the first attempt in the UK to make an integrated set of recommendations,
for fat, starch, ugar, and fibre, in a report expanded from its original
brief which had been to update the 1979 report on energy (calories), protein,
vitamins and minerals.
In some respects this new COMA report, also known as the 'Dietary Reference
Values' report ([)RV )r short) is admirable. In sharp contrast to other
officially recognised expert reports on nutrition and public health published
in the UK, it is detailed (a total of 210 pages), and includes careful references
) the scientific literature which enable the reader to follow its thinking.
It is also comprehensive: The most obvious change is the range of nutrients
covered. Previously COMA has considered only 10 nutrients in detail; this
time the number is around 40.' These include many vitamins and minerals
now known to be important to public health which have not been previously
recognised as such in the UK, including vitamin B6, folic acid (or folate,
another B vitamin), and various minerals and trace elements such as magnesium,
potassium, zinc, selenium, and chromium. (Judgement of the merits of the
DRV report's views on vitamins and minerals is outside the scope of this
be exciting feature of the DRY report is that at last, years after most
other major industrialised countries had issued dietary guidelines reports
about fat, saturated fat, starch, sugar, fibre, and salt, ie official UK
Committee on Medical Aspects of Food Policy did likewise. Indeed, the DRY
report oes further, and specifies 'reference values' with figures for all
these nutrients. Previewing the report an excited cover feature in 'New
Nutritionists in Britain will have a new and controversial set of figures
to play with: revised estimates of the amounts of nutrients needed for a
balanced national diet. The figures come from what is probably the largest
survey ever made of published studies on diet and will help nutritionists
and government policy makers to set national dietary goals. The figures
are also likely to cause a storm, for they imply that people in Britain
must make drastic cuts in their consumption of fat and sugar. Although the
report itself offers no recommendations about healthier eating, consumer
groups are ready to seize on the findings to demand corresponding changes
in dietary advice.
Given the status of the Committee on Medical Aspects of Food Policy, it
is fair to say that the DRY report marks an official change of heart. After
a decade and more of pressure from the scientific community, other health
professionals, consumer groups, environmentalists, and indeed key sectors
of the food industry, the UK Government has finally recognised that the
national diet amounts to a major public health problem. In setting 'reference
values', the expert panel makes specific reference to coronary heart disease,
high blood pressure, other diseases of the circulation system, cancers including
of the breast and colon, obesity, digestive diseases and disorders, and
tooth decay. While the report is cautious, frequently emphasising that evidence
is incomplete and that more research is needed, it nevertheless reaches
Thus, while 'only about 5 per cent of adults in the UK currently derive
10 per cent of energy or less from saturated fatty acids' the report proposes
Saturated fatty acids should provide an average for the population of
10 per cent of total dietary energy.
While this recommendation is complicated by a further proposal that not
more than a further 2 per cent of energy be derived from trans fatty acids,
which are chemically like polyunsaturates but from the health point of view are like saturates, the 1991 COMA recommendation is rather more radical
than that of the 1984 COMA panel on 'Diet and Cardiovascular Disease', which
recommended a maximum of 15 per cent of energy from saturated fat.
Again, while 'total sugars, at 99 grams per person per day, contributed
16 per cent of energy' on average in the UK, the report points out that
in societies where the total amount of sugar in the food supply is less
than 10 per cent of energy, tooth decay is rare. Sugar in natural form,
as in fruit, is h&mless: but 'non-milk extrinsic sugars', notably sucrose
and glucose purchased as such or else eaten in processed foods, are harmful
in the quantities consumed in the UK. The report proposes that:
The population's average intake of non-milk extrinsic sugars should
not exceed 10 per cent of dietary energy.
Furthermore, 'The panel agreed that carbohydrate should provide the major
food energy requirement for UK populations', and it makes recommendations
for consumption of foods rich in starch and fibre that are in effect much
the same as those included in the NACNE report,119 and in the 1988 World
Health Organisation report for Europe, 'Healthy Nutrition' In 1991, therefore,
an official UK expert report at last made recommendations in line with the
world-wide scientific consensus on food, nutrition and public health.
Dietary recommendations for the world
It was in this context that the World Health Organisation convened a study
group of leading nutritional scientists, who met in Geneva on 6 - 13 March
1989. Members of the group came from Africa, Australia, Canada, China, India,
Italy, Japan, the UK, the USA and the USSR. Professor Philip James from
the UK, previously chief author of the 1983 NACNE report and of the 1988
WHO report for Europe, 'Healthy Nutrition', was appointed chairman of the
Its brief was to: 287
Define recent changes in the dietary and health patterns of countries,
define the relationship between the 'affluent' diet that typically accompanied
economic development and the subsequent emergence of chronic diseases, and
explore the need for national food and nutrition policies to prevent or
minimise costly health problems in both developing and developed countries.
That is to say, Professor James and his colleagues were charged not only
to compile an expert report on dietary guidelines for everyone in the world,
but also in effect to devise a global blueprint for the improvement of public
health by means of good food. The resulting report, 'Diet, Nutrition,
and the Prevention of Chronic Diseases'287 was published by WHO late
in 1990; it is the one hundredth of the 100 expert reports to be analysed
in this review. Its scope is outlined in an 'Executive Summary' published
by the WHO Secretariat in Geneva, designed to accompany the report and to
explain its purpose:
Medical and scientific research has established clear links between
dietary factors and the risk of developing coronary heart disease, hypertension,
stroke, several cancers, osteoporosis, diabetes, and other chronic diseases.
This knowledge is now sufficiently strong to enable governments to assess
national eating patterns, identify risks, and then protect their populations
through policies that make healthy food choices the easy choices. The population
nutrient goals developed in the report are put forward to assist in this
Professor James and his colleagues were supported in their work by representatives
of international organisations, such as the UN Food and Agriculture Organisation,
the International Diabetes Federation, the World Hypertension League, and
the International Union Against Cancer. 'Diet, Nutrition, and the Prevention
of Chronic Diseases', while basing its conclusions and recommendations on
the latest scientific evidence, is also built on the work done by others:
it includes summaries of the findings of over 50 other expert reports (almost
all of which are reviewed here and analysed in Annex One).
Previously, scientists concerned with the public health problems caused
by dietary deficiency, had worked and thought separately from scientists
concerned with the public health problems caused by imbalance and excess.
What, after all, do the nutritional needs of a starving child in Africa
have in common with those of an obese adult in America? But one of the key
achievements of the 1990 WHO report is that it sets goals expressed as ranges
of nutrients, designed to work both for developing and developed countries.
In the words of the Executive Summary:
The report issues a series of 'population nutrient goals' put forward
as a universal guide to the nutrient intakes needed to prevent all diet-related
diseases and appropriate for application in all countries throughout the
world. Lower and upper intakes are set for each of the main nutrient groups,
including total fat, saturated fatty acids, polyunsaturated fatty acids,
protein, total carbohydrates, complex carbohydrates, and free sugars. Expressed
as a proportion of total energy, this recommended 'safe' range of intakes
specifies the minimum intake of a nutrient needed to prevent deficiency
diseases and the maximum intakes that should not be exceeded in the interest
of preventing chronic diseases. Recommended daily intakes, expressed as
grams, are issued for salt, dietary fibre, dietary cholesterol, and fruits
The central thesis of the 1990 WHO report is good news for everybody, everywhere.
It is that the diet most likely to prevent a great range of chronic diseases,
including overweight and obesity, and to promote general good health throughout
life, is the same diet the world over: for men, women and children.
A healthy diet has infinite variety. Traditional cuisines throughout the
world are healthy, provided that simple meals based on starchy staples together
with vegetables and fruit are eaten from day to day, and that more elaborate
meals including substantial amounts of fat, sugar - and alcohol - are consumed
only as occasional feasts. Key advice is always to prefer 'nutrient-dense'
to 'energy-dense' foods. Again, in the words of the Executive Summary:
Energy-dense foods are generally not rich in nutrients. Though foods
processed with sucrose may carry a number of nutrients, sucrose does not,
in itself, meet any special nutritional requirement. Fat carries its few
nutrients in the form of fat-soluble vitamins. Alcohol, which is also energy-dense,
is accompanied by few if any nutrients.
The 1990 WHO report is altogether more radical then any other expert report
reviewed here. The goals it sets for total fat consumption, are between
15 and 30 per cent of total energy (calories); and for saturated fat, between
0 and 10 per cent:
Since there is no requirement for saturated fatty acids per se (except
as part of the total intake) the lower limit has been set at 0 per cent
The goals set for polyunsaturated fats are between 3 and 7 per cent of total
energy, reflecting the view held by most scientists outside the USA that
a goal of 10 per cent is too enthusiastic.
The sharpest possible contrast is drawn between complex carbohydrates, contained
in grains and other starchy foods, legumes and vegetables, on the one hand,
and on the other hand 'free sugars', which is to say refined or extrinsic
sugar. 'The intent is to maximise the intake of complex carbohydrate and
minimise the intake of free sugars.' The goals set are: complex carbohydrates,
between 50 and 70 per cent of total energy (calories); free sugars, between
0 and 10 per cent.
Dental caries rates increase progressively with increase in population
sucrose intakes ... The other concern relating to excessive use of free
sugars is that they provide energy without associated nutrients and have
displaced nutrient-containing foods ... The upper limit of the population
nutrient goal for free sugars should be about 10 per cent of total energy.
There is no lower limit.
Also the report sets a target, for fruits and vegetables: a minimum of 400
grams, or just under a pound, a day:
The recommendation is made recognising the epidemiological evidence
of an increased risk of cancer with low intakes of certain fruits and vegetables
... The recommended lower limit is higher than current intakes in many populations
and much higher than current intakes in some of the developed countries.
No upper limit has been suggested.
In other words, for all practical purposes, the more vegetables and fruits
everybody eats, the better. The goal set for dietary fibre, is between 27
and 40 grams a day; for salt, an upper limit of 6 grams day; for dietary
cholesterol, between 0-300 milligrams a day; and alcohol is not recommended.
That sort of diet is implied by these 1990 WHO goals? The Executive Summary
In both affluent and developing countries, the dietary pattern associated
with an increased risk of chronic diseases is characterised by high consumption
of sugar-rich foods and of those meat and other animal products rich in
saturated fat and dietary cholesterol. These foods now fill up the space
in the diet previously - and historically - held by the starchy, complex
carbohydrates. The population nutrient intakes recommended in this report
translate into a diet that is low in fat, and extremely low in saturated
fat, and high in complex starchy carbohydrates. Such a diet is characterised by frequent consumption of
vegetables, fruits, cereals and legumes, and contrasts sharply with current
diets drawing substantial amounts of energy from whole-milk dairy products,
fatty meats, and refined sugars.
How to create change to healthy diets? The 1990 WHO report is a political
as well as a scientific report, and its proposals, in compressed language,
Many non-nutritional factors can lead to the success or failure of
nutrition and food policies. Consequently, in addition to being physiologically
sound, they must be politically viable, economically feasible, and culturally
acceptable. To achieve this, food and nutrition policies must have the credibility
provided by scientific and epidemiological evidence, have political and
technical support, and be regarded as necessary and convenient by the consumer.
All this indicates that the development and implementation of food and nutrition
policies require multisectoral government action. These actions need to
be co-ordinated to be effective; they should involve the whole food chain,
from the consumption or importation of food through to its consumption.
The vision is comparable with that of John Boyd Orr over half a century
previously, in his 'Food Health and Income':217
From the point of view of the State, the adoption of a standard of
diet lower than the optimum is uneconomic. It leads to a great amount of
preventable disease and ill-health which lay a heavy financial burden on
the State... It is probable that an enquiry would show that the cost of
bringing a diet adequate for health within the purchasing power of the poorest
would be less than the cost of treating the disease and ill-health which
would thereby be prevented ... It remains ... to adjust our food policy
so that the great wealth of food which we have or can produce will be brought
within the purchasing power of the poorest. This is no easy task. It will
require economic statesmanship of the highest order. But in a democratic
country the necessary legislation must be preceded by an intelligent demand
on the part of the people.
'Diet, Nutrition and the Prevention of Chronic Diseases' sets out a political
and economic agenda, including a 22-point plan addressed to the World Health
Organisation, and to national governments:
Governments and communities in both developing and developed countries
should act now to reduce the future burden of these diseases. Their prevention
or reduction is both a social responsibility and an economic necessity.
Each Ministry of Health should, as part of its health promotion programme,
establish regular contact with non-governmental organisations, consumer
representatives, and the media to develop jointly a community-based programme.
This activity should be in addition to any government- sponsored health promotion
In the UK, Consumers' Association, funded solely from the subscriptions
of almost one million members, convened a 'Healthy Eating Campaign' early
in 1990, to promulgate the WHO report at its British launch in the Houses
of Parliament in April 1991. Dr John Beishon, Chief Executive of Consumers'
Association, had this to say: 289
The WHO report is a consumer report. It deals with what is perhaps
our most precious possession, our good health and span of life. None should
be surprised that Consumers' Association is involved in the Healthy Eating
Campaign and that we consider it to be one of the most important campaigns
we have ever worked on. We are particularly pleased that the Campaign is
a coalition of the Coronary Prevention Group, the Guild of Food Writers,
the National Federation of Women's Institutes, and ourselves. Both the Health
Education Authority and the National Consumer Council support our overall
aims. All are with us today. Our strength as individual organisations is
vastly multiplied when we can work together like this.
The Guild of Food Writers, the professional association of food writers
in the UK, produced a booklet, 'Eat Well ... Live Well!' to accompany the
WHO report, designed to translate its scientific recommendations about diet
and disease into plain-language recommendations about food and health for
everybody in the UK. In this 16-page, large-format booklet, all foods are
divided into three groups. First, vegetables, salads and fruits with the
headline 'Eat as much as you want.. and stay healthy'. Summarised, the story
Eat vegetables, salads or fruit with every meal. Snack on fresh fruit
and remember you can eat as much of these foods as you like. There's no
Second, bread, potatoes and cereals, whose headline is 'Satisfy the heartiest
appetite...and stay slim!'. Here, the message is:
Eat bread, cereals and potatoes and other starchy goods with every
meal, and snack on sandwiches and other breads. They're satisfying and full
Third, meat, fish and dairy foods, whose headline is 'Choose for quality..
.and protect your health'. Here, 'quality' means lean meat and low-fat dairy
The message is:
Eat as much fish as you like. If you like meat, eat meat not fat.
Choose low-fat dairy foods or just eat them less often.
And snacks and meals? 'By putting together the foods from these three groups,
you can make healthy and delicious meals and snacks. Vegetarians and vegans
can simply leave out the last group as appropriate.' Finally, 'Seven steps
to healthy eating', following the nutritional principles of the WHO report,
are set out:
1. Abundance. Eat at least five portions 6f fruit and vegetables every
William Waldergrave, UK Secretary of State for Health, was evidently impressed.
At the 9th July 1991 launch of the COMA DRV report, he acknowledged that
the scientific recommendations of the report had to be translated into plain
language in order to impress the British people, saying:
2. Satisfaction. Include bread, potatoes or cereal foods with every meal.
3. Quality. Choose lean meat and low-fat dairy products and all types of
4. Value. Make healthy foods into good value, delicious meals and snacks.
5. Nourishment. Keep consumption of fat, sugar and salt to a minimum.
6. Pleasure. Enjoy the variety of foods form all over the world.
7. Choice. Insist on healthy food, as a consumer and as a citizen.
There's a huge piblic education and transmission and translation
job now to be done .... There are some very good private sector and voluntary
organisation campaigns going on , too.
And as he spoke, he held up a copy of 'Eat Well ...... Live Well!'.
Published in 1992 by:
© Consumers' Association Ltd and Geoffrey Cannon
2 Marylebone Road
London NW1 4DF
ISBN 0 85202 449 5