NHD Issue 148 Public health messages for a healthy diet By Dr Michele Sadler

PUBLIC HEALTH

Dr Michele Sadler Consultant Nutritionist, Rank Nutrition Ltd Michele is Director of Rank Nutrition Ltd, which provides nutrition consultancy services to the food industry.

Michele has a BSc in Nutrition (University of London), a PhD in Biochemistry and Nutritional Toxicology (University of Surrey), and is a Registered Nutritionist.

REFERENCES Please visit the Subscriber zone at NHDmag.com

PUBLIC HEALTH MESSAGES FOR A HEALTHY DIET In response to increasing nutritional challenges, including the rise in the prevalence of obesity and Type 2 diabetes amongst other diet-related conditions, public health messages have an important role in educating the public about healthy eating. But is education alone sufficient to change public behaviour, and what is the future for such messages?

Public health messages for a healthy diet are the responsibility of Public Health England (PHE), an executive agency of the Department of Health and Social Care (DHSC). The role of PHE is to improve the health and wellbeing of the population and to reduce health inequalities, through the provision of evidence-based advice and scientific expertise. In fulfilling this role, PHE takes advice from the Scientific Advisory Committee on Nutrition (SACN), which consists of independent experts that advise government about nutrition science, diet and health.

UK government recommendations on diet and nutrition have tended to remain fairly constant over the years.

The most recent significant changes were in 2015 when the recommendation for maximum sugar intake was halved and the recommendation for fibre intake was increased.

EATWELL GUIDE

A cornerstone of public health messages about diet and nutrition is the PHE Eatwell Guide.1 This is based on reports from the former UK Committee on Medical Aspects of Food Policy (COMA)2,3 WHO4,5 and SACN.6-11 Updated in 2016, the pictorial Eatwell Guide summarises the key dietary messages in terms of five food groups for people aged five years and over (see Table 1 overleaf).

The Eatwell Guide also advises the public to eat sugary foods less often and in small amounts and drink six to eight glasses of fluid per day, including water, lower-fat milk, and sugar-free drinks such as tea and coffee.

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DIETARY SUPPLEMENT RECOMMENDATIONS

A number of public health messages recommend that targeted population groups should take specific dietary supplements (see Table 2 overleaf).

Folic acid and vitamin D supplements are recommended for these groups because it is difficult to get sufficient intake from food sources alone. Specific supplements are recommended for pregnant women on low incomes and small children, to ensure adequate intakes of particular vitamins that may be vulnerable in their diets.

COMMUNICATION OF PUBLIC HEALTH MESSAGES

A main vehicle for communicating PHE advice directly to the public is via the NHS website.15 Another means of reaching consumers is the Government’s advertising programme Change4Life,16 which aims to help families adopt healthier lifestyles by eating well and moving more. Health professionals and their associations such as the BDA, along with organisations such as the BNF, also have a pivotal role in communicating nutritional messages to the public. These organisations have an important role too, in interpreting scientific information and advice for journalists. Additionally, since the media, and more recently the social media platforms, are a major source of public information on diet and health, nutritionists working in the media also have a positive impact, ensuring that messages are scientifically accurate and consumer-friendly.

PUBLIC HEALTH Table 1: Key Public health messages in the Eatwell Guide* Food group Fruit and vegetables Potatoes, bread, rice, pasta and other starchy carbohydrates Beans, pulses, fish, eggs, meat and other proteins Dairy and alternatives Oils and spreads

Public health messages Eat at least five portions of a variety of fruit and vegetables every day.

Choose wholegrain or higher fibre versions with less added fat, salt and sugar.

Eat more beans and pulses.

Eat two portions of sustainably sourced fish per week, one of which is oily.

Eat less red and processed meat.

Choose lower fat and lower sugar options.

Choose unsaturated oils and use in small amounts.

*The Eatwell Guide does not apply to children under two years old and after this age, children’s diets should gradually adhere to the guidelines by the age of five years.

Table 2: Targeted dietary supplement recommendations Population group Women planning a pregnancy, from stopping contraception until the end of the first trimester of pregnancy Women with a previous neural tube defects-affected pregnancy, from stopping contraception until the end of the first trimester of pregnancy Children from one year of age, adolescents and adults, including pregnant and breastfeeding women Breastfed infants up to one year of age Bottle-fed infants up to one year of age consuming <500ml infant formula

Supplement

Aim

400mcg folic acid/day

To reduce risk of neural tube defects, such as spina bifida, in the foetus

5mg folic acid/day

As above

10mcg vitamin D/day, from October until April

To keep bones, teeth and muscles healthy

8.5-10mcg vitamin D/day

As above

8.5-10mcg vitamin D/day

As above

Children from birth to four years, consuming less than 500ml formula per day

233mcg vitamin A/day

Pregnant (at least 10 weeks) and breastfeeding women on benefits/tax credits; women aged under 18 years (start of pregnancy onwards) Women with heavy periods

ROLE OF HEALTH CLAIMS

20mg vitamin C/day 10mcg vitamin D/day 400mcg folic acid/day

For growth, vision in dim light and healthy skin To help maintain healthy tissue in the body As above As above

70mg vitamin C/day

As above

May need to take iron supplements

To reduce risk of iron deficiency anaemia

A further way in which consumers are exposed to positive dietary messages is via nutrition and health claims on food packs and websites.

The European regulation on claims17 is now firmly bedded in and only claims proven to be scientifically accurate are authorised for use.

Some claims back up public health messages, such as the disease risk reduction claim for folic acid supplementation that increases serum folate and reduces the risk of neural tube defects in the foetus.18

Interestingly, the claims regulation applies only to nutrition and health claims made in commercial communications and does not apply to claims made in dietary guidelines or advice issued by public health authorities and bodies. Hence, there is more freedom of communication for public health messages.

For example, the NHS website is able to refer to evidence that people who eat at least five portions of fruit and vegetables a day have a lower risk of heart disease, stroke and some cancers, whereas reference to disease is not www.NHDmag.com October 2019 - Issue 148

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PUBLIC HEALTH permitted on a food label, or on a related commercial website.

GAPS AND CHANGES IN PUBLIC HEALTH MESSAGES

While current public health messages are pretty comprehensive in addressing healthy eating advice and diet-related disease, a possible area for further public advice would be to address low micronutrient intakes in teenage girls.19,20 Whilst eating a diet that follows the Eatwell Guide will help to ensure adequate micronutrient intake, in this particular population group a targeted message may be helpful to reinforce the important contribution of specific food groups for ensuring adequate intakes of vulnerable micronutrients. For example, in years seven to eight of the NDNS Rolling Programme,20 54% of teenage girls (11-18 years) had iron intakes below the Lower Reference Nutrient Intake (LRNI), 22% had calcium intakes below the LRNI and 15% had folate intakes below the LRNI. There was evidence of both iron-deficiency anaemia (as indicated by low haemoglobin levels) and low iron stores (plasma ferritin) in 9% of teenage girls, as well as evidence of low blood folate levels indicating risk of anaemia in over a quarter (28%) of teenage girls. Targeting this population group is particularly important since teenage girls are future mothers. There is a growing body of evidence to support developmental origins of health and disease, ie, that undernutrition during gestation leads to foetal programming, which permanently shapes structure, function and metabolism and contributes to adult disease, potentially in more than one future generation.21 A further point raised in the literature is the appropriateness of the qualification that eating dried fruit should be limited to mealtimes. The advice is given in light of concerns that dried fruit may be harmful to teeth, but a review found very little evidence to support this.22 ARE PUBLIC HEALTH MESSAGES WORKING?

The current levels of obesity in the population and the rising tide of Type-2 diabetes, suggest that simply giving the public advice about diet and healthy eating is insufficient to encourage the adoption of healthy lifestyles. In recent years, other approaches have been adopted, such as 10

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the drive to remove excess salt and sugar from processed food, the sugar tax on soft drinks and the government’s childhood obesity strategy.

There is a view that a more interventionist approach is needed to bring about changes in the food supply and to help nudge people in the right direction. Professor Dame Sally Davies’s 10th Annual Report23 focused on the future health of England’s population. Taking an aspirational view of what good health could look like in 2040, the report considered changing behaviour in relation to diet, alcohol consumption, smoking and physical activity and concluded that an environment needs to be developed to make the healthy choice the easy choice in order to promote health. The report proposed a future aspiration that reform of the economic and commercial environment will lead to a shift in the food system from one incentivised by profitability, to one driven by healthiness and sustainability of food.

In this scenario, business growth would require a value-creating and health-enhancing approach, resulting in dietary benefits for the population.

Strategies to improve health could include fiscal measures that incentivise businesses to improve access to nutritious foods and disincentivise the production of energy-dense products. The report suggests that this could have a greater impact on health than interventions that focus on choices made by individuals.

CONCLUSION

In the face of increasing nutritional challenges, policy has moved forward such that public health messages are no longer the only measure for achieving population health through dietary change. Whilst they are a supportive educative measure, they now work alongside other strategies and approaches to help improve people’s diets. Should the future lead to the use of different and more interventionist public polices to improve health, the scientific basis of the public health messages will, nevertheless, remain a crucial part of policy, as these messages crystallise the underlying scientific basis for actions that might be taken and the aims of different policies. Hence public health messages will remain an important tool in the quest for achieving public health through improved diet and lifestyle.