Food and public health

Wednesday 1 October 2003

2003 Harben Lecture, Royal Institute of Public Health, London.

1. Introduction
Thank you for inviting me to give this year's Harben Lecture. Following in the footsteps of such distinguished predecessors, I feel greatly honoured to be here.

I am especially pleased that by inviting me you've signalled the importance of food: that what we eat is fundamental to public health and that one of the shared aims of our two institutions, the Food Standards Agency and the Royal Institute of Public Health, is to protect public health in relation to food.

This is by no means the first time you have had a food theme to the Harben Lecture. Looking back over the list of previous topics, I note, for instance, that in 1939, 1941 and again in 1989, your speakers took nutrition as their theme – and nutrition will be part of my theme for this evening.

Of course, if we look at the broader spectrum of great scientists of the past, from Louis Pasteur to Boyd-Orr, we see that for well over 100 years experts have been concerned with food safety and diet as contributors to public health.

In Sir Donald Acheson's own 1998 enquiry, Inequalities in Health, the link between food and public health was clearly drawn out, and I think many of the messages that I will give this evening resonate with the messages in that very important report.

Food risks and public health
Let's start by asking how important food and diet is in relation to public health, given that in today's Britain few, if any, are short of food. It's not like the situation 150 years ago, when many people were starving.

The numbers I'm going to show you are only very approximate, but if we take the work of epidemiologists such as Sir Richard Doll (who himself was a previous Harben Lecturer), then as much as one third of cardiovascular disease risk and at least one quarter of cancer risk is related to diet. Between them these two big killers account for around 100,000 premature deaths per year related to the food we eat in one way or another.

More recently, much has been written about the dramatic increase in obesity, which now affects about 8 million adults and over a million children in the UK, and if the recent time trend continues this figure will double in about 10 years. Obesity is bringing new public health risks, such as type 2 diabetes, which now affects 1.7 million people in Britain. Of course, obesity is not exclusively caused by diet (and I will return to this later), but it would be hard to deny that how much we eat, and what we eat, has a role to play.

There are also other food risks can also have a big effect on our health.

Foodborne illness probably affects about 1.3 million people a year and causes about 500 deaths.

Food allergy is an issue. It's estimated that up to two million adults and children are allergic to, or intolerant of, some kind of food, and in extreme cases, perhaps for about 10 people a year, this can cause death by anaphylaxis.

Finally I will mention the human manifestation of BSE, variant CJD, which has mercifully counted for only about 140 deaths so far, though its effects are devastating and tragic, and there are still many uncertainties in the scientific knowledge of this disease.

Having been given that snapshot, you may feel completely un-nerved – but I don't want you to think that food is all gloom and disaster and risk. Far from it; for most of us, most of the time, food is a source of sustenance and pleasure, rather than a clear and present danger. Although like everything else in life, it is not risk free.

Nor, if you do consumer research, do you find that in general, people worry about food safety. And when they do, the kinds of things they worry about are food poisoning, BSE, pesticides, additives, and animal feed. Healthy eating or diet and nutrition come relatively low on people's risk register.

2. The role of the FSA
It is against this background that I want to talk about the work of the FSA. The FSA has now had 3.5 years on its job of protecting public health and other consumer interests in relation to food. You will no doubt be relieved to hear that I am not going to go through everything the FSA has done, or is intending to do, to protect public health.

Instead, I want to share some thoughts with you about our general principles, and then take two specific examples from our work, to lend, as WS Gilbert put it, a 'touch of verisimilitude to an otherwise bald and unconvincing narrative'.

Educate or regulate?
I will start with a few questions.

Here we are as a new Government department set up to protect public health in relation to food. What is the most effective and appropriate way for Government to carry out this function?

When and by what degree should Government intervene by regulation?

When is it more appropriate simply to provide people with information and let them decide?

When is it best to manage risks and protect public health through voluntary action involving perhaps the food industry, public health specialists and those involved in enforcement?

Of course, in real life the answer will be a mix of these three (and perhaps other) approaches. The mix is a matter of judgement and balance. What level of regulation is proportional to the risks? What is practicable and enforceable? How does intervention restrict individual choice, freedom and responsibility? Do those most in need of help actually have the freedom to choose?

These are the sorts of questions that we have to address in formulating policy and advice to Government.

3. Foodborne illness
Let me take foodborne illness (food poisoning for short) as my first example. The Agency in its first year set itself a target of reducing food poisoning by 20% by 2006. A very significant target and some of the food microbiologists that I spoke to at the time said, 'You must be mad to set a target like that.' That's one point of view, but I think it is important to have targets, and I think we are doing important things to meet the target.

To achieve this we are using a mixture of changes, involving regulation, voluntary action, education, and individual responsibility.

First, we need to go right to the start of the food chain to reduce the prevalence of disease agents that cause illness. The commonest causes of food poisoning are bacteria such as campylobacter and salmonella that live in animals, so reducing their prevalence in farm animals is likely to reduce food poisoning.

Second, we need to ensure that the people who prepare and handle our food for us manage the risks effectively on our behalf.

Third, we need to encourage the general public to protect itself by common sense good hygiene.

Campylobacter
A few years ago in relation to food safety, all the talk was of salmonella, especially in poultry. But the poultry industry appears to have been successful in getting the prevalence of salmonella down from over 30% in the mid 1990s to less than 6% of retail chicken by 2002 in an FSA survey. Probably, the prevalence in eggs has come down as well.

So salmonella is no longer at the front of the pack. Instead, campylobacter is now in pole position in the food poisoning stakes. It is responsible for about three-quarters of all clinically confirmed cases of food poisoning.

If you look at chicken on sale in the shops, more than half is contaminated with campylobacter, so the top priority in our foodborne illness strategy for the 'farm' end is to find ways of reducing campylobacter in chickens.

The first step is to improve bio-security on broiler farms. It seems that even if a flock of chickens starts out free of campylobacter, the disease often suddenly appears after the first 21 days of the 50-day rearing period. Although we don't know for certain, the likelihood is that it is brought into the broiler house accidentally by people or wild animals, or through the ventilation system.

Now I said that 50% of chicken on sale contains campylobacter, so it is clear that some farmers are able to produce campylobacter-free broiler chickens. They can give us some clues as to how to advise the rest.

A bigger challenge will be free range chickens. Even if the name conjures up to some consumers happy, healthy, disease-free birds, the fact is that free-range chickens are more likely to be contaminated with campylobacter than broiler chickens, because the bacterium is common in wild birds and mammals. And therefore bio-security is a bigger challenge.

It seem to me that in the longer run, research on the population dynamics of infection and transmission may help to determine how to control the disease even when chickens go outside.

We plan to help chicken farmers with our advice, but consumers could also vote with their purses. But in order to do this people need to know which farmers have taken on board effective management of the risk.

There is a phenomenon that you may all be familiar with called assurance schemes, such as the Red Tractor, which are meant to be a way of telling people about the way farmers produce food. Perhaps including management of risks such as campylobacter. But our research shows that at the moment the public is in a complete fog about what these logos, seen on so many kinds of food in the supermarket, actually mean.

I was on a radio phone-in programme last year in which the host asked somebody if he knew what the lion brand on eggs meant. The caller quipped back that he thought it meant they were laid by lions! I wonder how many of you, for example, know exactly what the difference is between a piece of chicken that you buy in the shops that has a Red Tractor on it, and piece that doesn't?

So, there is a possibility of using consumer pressure to drive up standards. But if that possibility is to be realised there needs to be greater transparency. And people need to learn what the symbols mean so that they can chose, if they like what the symbol is telling them.

Food Safety Management
But however good the risk management on the farm, meat will never be free of bacteria, which is why the people who process, manufacture, prepare and serve our food should also know how to manage food risk.

Within this panoply of activity in the food industry we are putting special effort into devising ways of getting catering businesses to adopt proper food safety management.

Why caterers?

This is because of the huge number of catering premises: about 300,000 in the UK, many of them very small and with a high turnover of very unskilled staff.

And our own surveys show up some pretty horrifying facts. Did you know, for instance, that about 40% of restaurant workers when asked do not wash their hands after going to the loo and a little more than half do not do so before preparing the food you and I eat? Think about this as you enjoy your food later on this evening.

Is this a case for regulation or education? Three years ago the FSA brought in a new regulation requiring licensing for butchers, in the wake of the Lanarkshire E. coli problem. And there are those in the consumer movement who say we should do the same for restaurants. They say it's absolutely outrageous that people should be able to cook and serve food, putting lives at risk, without being licensed to do so.

We haven't ruled out licensing, but we still have to be convinced that the risks justify a universal licensing system that could be very costly in time and money for local authorities to implement and monitor. Perhaps more fundamentally, there would be little point in requiring licences without the training in food safety management that caterers need in order to get the licence and to avoid unwittingly giving their customers more than a good meal.

So at this stage we want to support environmental health officers by producing the right kind of information packs to enable caterers to manage food safely in their businesses. This is not easy, bearing in mind the small scale and low skill level of many food catering outlets. Any system we develop, and we are in consultation with enforcement officers and businesses, has to be very simple, practical, effective, and easily translated into action.

The fundamental principles of food hygiene are the HACCP principles – which are quite structured and bureaucratic – are difficult to teach to a teenager whose principle language is not English and who may be only going to work in the business for a week anyway. So we need something that embodies the basic core information but which is simpler to understand and express.

That's education, and improvements for the skill base and upping the standards.

But there is going to be a legislative side as well. From 2006 onwards, under European legislation, all food businesses will have to have a documented system of food safety management. At the moment only about 20% in the UK do, so there's a very steep hill to climb over the next few years.

Finally, on the subject of food poisoning, what about the consumer at home? Many people, it turns out, are blissfully unaware of the basics such as hand washing and cross contamination. Which is why, in addition to our educational initiatives with the catering sector, we are also working with the Department for Education and Skills to improve food hygiene and other food training in schools, and also using TV advertising and other information to raise awareness with the general public.

To summarise, no one group has responsibility for food safety: everyone from the farmer to the consumer at home has a part. To bring about change will take time and a mixture of new regulation, better knowledge both for consumers and for people working in the food industry, and better standards.

4. Diet and health
You may think that our target to reduce food poisoning by 20% in five years is pretty ambitious – although the early signs suggest that we are on course so far.

But if you think tackling food poisoning is tough, what about our aim of improving people's dietary health? At least with food poisoning we know the causes and can identify the potential levers to reduce and manage the risk. In many aspects of diet and health, both the science underpinning risk assessment and the ways to bring about change are much less clear cut.

Also any measurable improvement in public health would be long term, the effects of diet on health being chronic rather than acute. Nevertheless, as I pointed out earlier, the biggest food risks we face are those associated with diet and health.

However, Government intervention to improve dietary health is a political minefield. Diet and health is generally seen as an individual lifestyle choice, and intervention might not only infringe individual liberties but also stigmatise people deemed to be making 'bad choices'.

The problem
What is the problem with the average diet in the UK?

The best information on what people eat comes from the National Diet and Nutrition Surveys, carried out on behalf of the FSA and Department of Health. These not only record detailed food diaries of about 2,000 volunteers, but also measure nutritional status from blood and urine samples.

There are also other surveys, such as the Expenditure and Food Survey (formerly the National Food Survey), but this is based on household food purchases rather than individual intakes and does not measure nutritional status.

At the moment the FSA is publishing the results of its latest National Diet and Nutrition Survey of adults (19-64). The results give both a snapshot of the present situation and a comparison with the last survey done 15 years ago. The final summary won't be out until early next year, but the results so far show a number of clear patterns.

Compared with what people are eating today (by which I mean 2001, when the data were actually collected) with what the experts advise is a balanced diet we see some clear differences. People on average eat nearly 60% too much salt, 20% too much sugar, 25% too much saturated fat, and only about half the recommended intake of fruit and vegetables. No surprises here.

What I think is particularly interesting is that the time trends show that on salt the situation is getting worse. Over the last 15 years saturated fat has got slighty better. And on fruit and vegetables there is hardly any change, though possibly a slight improvement. So not a lot of change over 15 years. Dietary health has not improved as affluence has increased. And in one area, salt, it has got worse.

Now these are averages, but there is a clear pattern of variation across the population. To summarise succinctly, people from disadvantaged or lower socio-economic households tend to have poorer diets (as emphasised in the Acheson report). So diet is firmly on the inequalities agenda.

Linked to the question of dietary balance, is the overall pattern of energy intake and expenditure. This imbalance is causing the worldwide explosion of obesity, with enormous future public health consequences.

There is plenty of scope to argue about the relative importance of changes in energy expenditure and energy intake and I don't intend to enter into this debate now. But what can be said with some confidence is that obesity reflects lifestyle as a whole and not just the amount and kind of food eaten.

Nevertheless it is undeniable that in relation to people's expenditure, they are consuming too many calories. The evidence suggests (though there isn't very good data on this) that energy intake has actually gone down over the last 20 years but hasn't gone down enough to compensate for our decrease in energy expenditure.

For those of us over the age of 50, it is estimated that our extra expended energy when we were young, compared with today's children, is equivalent to running a marathon each week! So there has been a dramatic decrease in our expenditure of energy.

It is also undeniable that energy-dense food, high in fat and sugar, has become cheaper, more readily available, and, according to many consumers' perceptions, including mine, more heavily promoted.

And what is more, we increasingly rely on food manufactured and prepared by others: about one third of our weekly food budget is spent on catered food. So, our choices about our diet are often made by others.

Setting aside the Government's role in encouraging people to expend more energy, and I believe this is a hugely important area for public health improvement, I want to focus on diet.

Obesity has the highest profile at the moment, but diet and health goes much wider than this.

Nanny state: good or bad?
You don't have to look far to find that there are deeply entrenched and opposing views about what government should do to improve people's dietary health, including tackling the obesity time bomb.

At one end are pressure groups demanding more regulation, such as a tax on so-called 'bad foods' or a ban on advertising them to children.

At the other end are those, including most of the food industry, who would say that diet is a lifestyle choice and that no individual food is inherently good or bad; it's only the diet as a whole that affects health. The role of Government, according to this view, should be simply to educate or advise people about healthy eating. Anything else is branded pejoratively as 'nannying'.

Of course this begs the question of what to do if people ignore the advice. I am reminded of the quote from the Italian Transport Minister who referred to red traffic lights. In Milan they are instructions, in Rome suggestions and in Naples, Christmas decorations.

In the past few years there has been a discernible shift in public mood in the direction of regulation, partly fuelled by the alarming obesity figures, partly by putative legal actions in the US, and partly as a result of growing awareness of diet and health issues in general.

There is less talk of 'nanny state' and more talk of the need for action to tackle a growing, in two senses of the word, public health problem.

A recent report for the food industry by JP Morgan concludes that some form of regulation related to 'unhealthy foods' is possible or even likely.

Media interest is another index of public mood. In a mini-survey I carried out recently diet and health stories were getting about four times as much coverage as traditional food scares like cancer-causing chemicals or food poisoning.

Against this backdrop I want to touch on two pieces of our work aimed at contributing to improvement in dietary health.

Salt
The first is about salt, where we have both a robust scientific basis and an identifiable lever for bringing about change. Salt is, of course, an essential nutrient, but we eat too much of it and this is bad for our health.

Earlier this year our expert nutrition advisory committee, the Scientific Advisory Committee on Nutrition (SACN), completed a report that concluded that the scientific evidence linking salt intake and blood pressure has strengthened since COMA, the predecessor of SACN, last looked at this issue in 1994.

There would be significant improvements in public health if we could reduce the average adult salt intake from around 9.5 grams to 6 grams per day. The advice from SACN also, for the first time, set target levels for children.

One estimate, by Professor Graham McGregor, a vociferous campaigner for salt reduction, is that if the average adult consumption of salt in the UK went down by 3g, this would save 35,000 premature deaths a year from stroke.

Since the SACN report came out four months ago, we have discovered that things are getting worse not better.

The latest National Diet and Nutrition Survey shows that average salt intake of adults has actually increased over the last 15 years. On average we now consume 9.5g per day compared to 9g per day in 1986.

Unfortunately, about 75% of the salt we eat is added for us by others during processing or catering. So, simply exhorting people to add less salt at the table or in cooking would not crack the problem.

This is why we have been working, jointly with the Department of Health to persuade the food industry to reduce the salt levels in processed food.

Although the food industry tells as that they have already reduced the salt in some kinds of food (and we have independently verified this is true for bread, for example), they are not even doing as well as Alice's Red Queen. They may be running, but the population is still moving backwards.

We know that reductions can be achieved without sacrificing safety or acceptability. To make the point, if you buy a ready-made shepherds' pie from Safeway it contains twice as much salt, weight for weight, as the equivalent from Waitrose. If you go for Safeway's meal, you will eat about two thirds of your daily target at one go.

I think the food industry has a social responsibility to help people to help themselves, and they recognise this.

The food industry has come forward with proposals to reduce salt in certain foods. There's a particular initiative called Project Neptune, proposed by a consortium of food manufacturers to reduce salt in branded soups and sauces by 10% per year over the next three years. Sainsbury's is also developing a set of proposals for its own brand products.

These are an important start and we very much welcome them. But if you think of the journey from 9.5 grams to 6 grams as being like the trip from London to Edinburgh, the reduction in soups and sauces is a bit like getting past Hampstead on your way out of London!

It's a promising start, heading in the right direction, but there is still a long way to go.

To indicate just how far, we have developed a model based on the consumption patterns in the National Diet and Nutrition Survey which tell us how much different types of processed food contribute to the average intake of 9.5 grams. And therefore suggests figures of percentage reductions that would have to be achieved to get from London to Edinburgh. For instance 50% reduction in pizzas and a 50% reduction in cured meats like bacon and ham. This model is being published for discussion by health professionals and the food industry to try and stimulate the idea of exactly how far we need to go to get where we ideally would like to be.

Another route is through consumer pressure. If consumers ask for less salt then the retailers would no doubt respond. We are raising the profile of salt as a health issue and giving consumers information about the salt in their diets by publishing a series of surveys of salt in processed food.

We did ready meals earlier in the year and sausages last month, naming brands and explaining to people what the salt content is. If you give your child sausages, chips, and beans she will approach half her target intake in one meal.

For people who try to help themselves by reading the labels on food, things are not always crystal clear.

Salt is all too often labelled as sodium, which means nothing to the vast majority who do not happen to have at their fingertips the atomic weights of sodium and chlorine together with the chemical formula for salt!

So better labelling, not only in relation to salt, has to be part of the agenda of helping people to help themselves.

Salt will be at the top of our agenda for processed foods until we have made more progress. But in the future, we will want to consider other components, especially saturated fat and sugar.

Promotion and advertising to children
I now want to turn to our second piece of work on diet and health: promotion and advertising of food to children.

This is a popular target for campaigning organisations who point out that the vast advertising budgets (one estimate is $40 billion per year) of the food industry are spent to a large degree on promoting and advertising foods that are high in sugar, fat or salt.

In its recent report the Food Commission estimates that $500 is spent by the food industry in promoting 'less healthy' foods for every $1 spent by the WHO on preventing dietary related disease. The same report claims that more than half of all advertising on TV during children's programmes is for food and that 75% of this is for energy dense foods or drinks.

The images of fun, lifestyle and taste that the advertisements (including other forms of promotion such as free gifts) conjure up must, it is argued by the pressure groups, be powerful influences on food preferences and diet. Do children really have a free choice when bombarded with such inputs from one side of the dietary equation?

The food industry's counter argument, similar to that deployed by the tobacco industry in the past, is that advertising does not influence overall consumption but only brand loyalty and switching. They also point out that lots of other influences, the family, peers and so on are more important than advertising.

Of course, to claim that 'advertising causes bad diets' would be a vast oversimplification. The question is whether or not it plays a significant part.

Last week we published a systematic review of the research literature carried out by a team led by Gerard Hastings from Strathclyde University. This is the first thorough review of the literature. They started by looking at 30,000 abstracts and reports, filtering that down to about 100 that were sufficiently rigorous to be considered part of an evidence base.

They assessed the evidence for a series of propositions about the nature and impact of advertising. These include the kinds of food advertised, the channels used, the messages conveyed and, crucially, the impact on children's knowledge, preferences, and eating habits.

I do not have time to go through the detail, but the report's key conclusion is that advertising does have an effect on children's preferences and consumption and that it not only affects brand loyalty but also consumption of categories of foods, such as chocolates, crisps or fizzy drinks.

As you can imagine in this complex area of social science research, the evidence is not absolutely cut-and-dried, and it is virtually impossible to disentangle the quantitative contributions of advertising, family, peer pressure and other influences on food choices of children. So it is perhaps not too surprising that the food industry has also published a recent review, which reaches the opposite conclusion from ours.

We have called together a group of heavyweight experts from academia to look at the two conflicting reports and help us to understand better why they disagree.

If, for the moment, we accept that there is an effect (and a priori one might expect the industry to invest in advertising only if it pays), what options for action are available? If one takes the view that diet is a lifestyle choice, the answer may be 'do nothing'.

But faced with an obesity time bomb, in part caused by what people eat, as well as the other health consequences of bad diets, 'do nothing' may not be option for Government. This has particular relevance for children, for whom, it may be argued, society has a duty of care.

It is also increasingly accepted that waiting until people are sick and then paying to treat them is unsustainable. It just won't be possible to balance the books.

The industry already complies with codes of practice on TV and print advertising, but, if the Gerard Hastings' review is correct in its conclusions, perhaps these do not go far enough.

The FSA will decide on its advice to Government on this tricky issue early next year, after we have had chance to generate a public debate, listen to the views of stakeholders, and listen to the kind of reactions to a range of policy options that we will develop.

In the meanwhile there is a further dimension, which is the role of Government in supporting promotion initiatives.

Earlier this year, Cadbury's initiated the 'Get Active' scheme, which involved swapping sweet wrappers for sports kit in schools. This was officially endorsed by the Department of Culture Media and Sport. Our view was that Government should not support schemes of this kind, which might continue to encourage children to eat more than they should of the kinds of foods that we want them to eat less of.

Interestingly, in its half-yearly report in July, Cadbury Schweppes attributed its 5% increase in half-yearly sales to the success of the Get Active promotion.

5. Concluding remarks
During its first three years, the FSA's work in protecting public health was focused very much on what might be called traditional food safety issues. I could have spent the whole of this lecture talking about our work on BSE, or about dioxins, acrylamide, and other carcinogens found in food.

In the future, we will continue to maintain our work in traditional areas of food safety, but the importance of diet and health for us will increase.

It goes almost without saying that there is no magic bullet in improving dietary health and that in large part it is down to individuals. Past experience has shown that persuading people to change their behaviour to improve their health is not that easy.

However, as I hope I have argued, the notion of individual choice is not easy to characterise in the food environment we inhabit today. And as the congestion charge in central London shows, public acceptability of constraints on choice can change rapidly, especially when constraint is the new freedom.

Let me end on trust. Everyday the newspapers offer the latest dietary advice, mostly not founded on science, often conflicting, sometimes positively dangerous.

And things are going to get much more complicated in the future when we will all have our personalised optimum diet based on our genetic makeup – so-called nutritional genomics.

Who in this complex and confusing environment are people to trust?

The FSA has declared that it intends to be the country's most trusted source of information on food safety and nutrition.

Although these are still comparatively early days, all the indications are that we are beginning to earn trust. But trust is a fragile commodity. Far more easily lost than it is gained.

If we are to succeed in improving public health, trust is not an optional extra, it is essential. Perhaps our biggest future challenge will be to secure public recognition and trust.