Scottish Health Survey 2017 - volume one: main report

6. Diet

Joe Rose

Summary

• In 2017, as in previous years, mean fruit and vegetable consumption per day was higher among women (3.5 portions) than men (3.2 portions).

• One in five adults (19%) and children (20%) consumed a supplement containing vitamin D.
• Supplements containing folic acid were consumed by 7% of women (aged 16-49) in 2017.
• Around one in four people (24-25%) living in the two most deprived quintile areas reported current consumption of any form of supplement compared with around one in three (30-34%) of those living in the three least deprived quintile areas.

6.1 Introduction

Poor diet is a factor in one in five deaths around the world, and is the second highest risk factor for early death after smoking^[1]. In 2015 it was estimated that diets low in fruit and vegetables or high in sugar, processed foods or sodium directly accounted for 37% of all deaths and just over a quarter of the total global disease burden^[2]. Estimates from international comparisons have suggested that around a third of cases of cancer^[3] and cardiovascular disease^[4] worldwide could be prevented by changes in diet, both through improvements in nutritional content and overall reductions in body mass^[5].

Links between diet, in particular the role of saturated fat and fruit and vegetable intake and non-communicable diseases such as cancer, cardiovascular disease and Type 2 diabetes are well established^[6],^[7]. More recent research has broadened understanding of the role of fruit and vegetable intake in reducing the risk of non-communicable diseases. Studies have shown that vegetable consumption is more important than fruit consumption in reducing the risk of certain types of breast cancer^[8], stroke^[9], and diabetes^[10], while fruit consumption has been found to be more strongly associated with reducing the risk of coronary heart disease in women^[6] and oesophagal and stomach cancers^[11].

Other aspects of diet, including the potentially positive effects of fibre and wholegrains^[12], oily fish intake^[13]'^[14] and antioxidant vitamins^[15] have been studied in relation to cancer, cardiovascular disease and cognitive decline in later life. Folates have been shown to have a role in the prevention of neural tube defects^[16]; vitamin D and calcium are determinants of bone health^[17]; salt intake is linked to the development of hypertension^[18]; and the consumption of red or processed meat is linked to bowel cancer^[19],^[20]. Sugar is well established as a major cause of tooth decay^[21] and free sugars (or added sugars) have been linked to the development of obesity and Type 2 diabetes^[22]. In children and young people aged 11-18, sugary drinks have been identified as the key contributor to total sugar intake^[23].

It is difficult to determine with certainty the full economic burden of poor diet^[24]. However the economic impact on the NHS is apparent. Treatment of cardiovascular disease (including hypertension), cancer, Type 2 diabetes and tooth decay represent significant costs to the health service. The most recent evidence on the economic costs of risk factors for chronic disease suggests that unhealthy diet had an economic burden of £5.8 billion in 2006-07; a greater burden on the NHS than smoking, alcohol consumption, overweight and obesity or physical inactivity^[25].

This chapter includes information on food insecurity for the first time. A widely accepted definition of food insecurity is: 'the inability to acquire or consume an adequate quality or sufficient quantity of food in socially acceptable ways, or the uncertainty that one will be able to do so'^[26]. Evidence from the US and Canada suggests that food insecurity is a dimension of poverty that has specific consequences for diet and health and wellbeing. Household food insecurity is associated with inadequate intakes of certain nutrients and fruits and vegetables^[27]. Food insecurity can lead to the adoption of risk-averse food purchasing habits, where households prioritise purchasing foods that will not go to waste and that are most filling; often this means a reliance on cheap foods that are nutrient-poor but calorie-rich. Research has shown that food insecurity is associated with a range of negative health outcomes across the life cycle. For children, these include low birth weight and some birth defects, compromised development, cognitive problems, anxiety and depression, poorer health and higher odds of chronic conditions^[28]. Studies have shown that adults living in food insecure households have poorer mental health, poorer health and are more likely to suffer from chronic conditions such as diabetes, hypertension and mood and anxiety disorders^[28]. Food insecurity also makes it difficult to manage existing chronic conditions such as diabetes^[29].

6.1.1 Policy background

In Scotland there is wide recognition at national policy level that high consumption of foods high in fat, sugar and salt has wide-ranging consequences for the health of the nation^[30].

The Scottish Dietary Goals were revised in 2016^[31] and include:

• The World Health Organisation 5-a-day recommendation for adults (to consume at least five varied 80g portions of fruit and vegetables per day).
• To reduce salt intake from around 9g to 6g per day for adults.
• To reduce average calorie intake by 120 kcal per day and average intake of red meat to 70g per day.
• To provide advice on limiting fat and sugar intake and increasing consumption of fibre and oil-rich fish.
• To reduce the average intake of free sugars to 5% of total dietary energy.
• To increase intake of dietary fibre to 30g per day for adults.
• To maintain intakes of starchy carbohydrates at 50% of total dietary energy.

Existing UK healthy eating advice was also updated as the Eatwell Guide in 2016 to illustrate the proportions and types of foods from major food groups which would make up a healthy diet^[32]. Following recommendations from the Scientific Advisory Committee on Nutrition (SACN), Scottish Government advice on vitamin D for all age groups has also been updated^[33]. The Scottish Government is currently funding a number of programmes aimed at encouraging people to make healthier choices in the way they shop, cook and eat, through its Eat Better Feel Better campaign^[34]. The Programme for Government 2017-18 also sets out the Scottish Government's intention to progress measures limiting the marketing of products high in fat, sugar and salt^[35].

In October 2017 the Government undertook a public consultation on its plans to transform the wider food environment to improve diet and promote healthy weight among the Scottish population as detailed in A Healthier Future – action and ambitions on diet, activity and healthy weight^[36] responses were published in April 2018^[37].

Following this, in July 2018, the Scottish Government published A Healthier Future: Scotland's Diet and Healthy Weight Delivery Plan^[38]. The delivery plan includes an ambition to halve child obesity by 2030 and includes actions aimed at ensuring:

• Children have the best start in life – they eat well and have a healthy weight.
• The food environment supports healthy choices.
• People have access to effective weight management services.
• Leaders across all sectors promote healthy weight and diet.
• Diet related inequalities are reduced.

To encourage manufacturers to reduce the sugar content of their drinks, in 2016 the UK Government proposed a soft drinks industry levy^[39] to be paid across the UK by producers and importers of soft drinks that contain added sugar. Legislation was published in January 2018, and the levy came into effect on 6^th April 2018^[40]. Since it was first announced, over 50% of manufacturers have reduced the sugar content of their drinks, the equivalent of 45 million kg of sugar every year^[41].

In March 2017, Public Health England (PHE) published guidelines for its Sugar reduction programme^[42], which has a voluntary target to reduce by 20% by 2020 the level of sugar in the categories that contribute most to the intakes of children up to 18 years. Overall, there was a 2% reduction in the first year (against a target of 5%).

PHE's calorie reduction programme^[43] was published in March 2018. It challenges the food industry to achieve a 20% reduction in calories by 2024 in product categories that contribute significantly to children's calorie intakes (up to the age of 18 years) and where there is scope for substantial reformulation and/or portion size reduction. It does not cover foods included in the sugar reduction programme.

On food insecurity, a short-Life Independent Working Group on Food Poverty was established in 2015 to make recommendations to the Scottish Government on actions to tackle food insecurity in Scotland. The group recommended a range of measures focused on increasing incomes and developing sustainable, empowering, inclusive community food models^[44]. In particular, the Group recommended that: 'The Scottish Government should introduce and fund a robust system to measure food insecurity in Scotland, alongside wider measures of poverty'^[45].

6.1.2 Reporting on diet in the Scottish Health Survey (SHeS)

This chapter provides information on fruit and vegetable consumption among adults and children from 2003 to 2017. Figures on consumption of vitamin or mineral supplements for adults and children as well as food insecurity for adults are also provided for 2017.

The area deprivation data are presented in Scottish Index of Multiple Deprivation (SIMD) quintiles. Where appropriate, to ensure that comparisons are not confounded by different age profiles within categories, data have been age-standardised. Readers should refer to the Glossary at the end of this Volume for a detailed description of SIMD and age-standardisation.

Supplementary tables on diet are also published on the Scottish Health Survey website^[46].

6.2 Methods and Definitions

6.2.1 Measuring fruit and vegetable consumption

The module of questions on fruit and vegetable consumption was designed with the aim of providing sufficient detail to monitor population-level adherence to the 5-a-day recommendation. These questions have been asked of all adults (aged 16 and over) participating in the survey since 2003 and of children aged 2 to 15 since 2008.

The module includes questions on consumption of the following food types in the 24 hours to midnight preceding the interview:

• vegetables (fresh, frozen or canned);
• salads;
• pulses;
• vegetables in composites (e.g. vegetable chilli);
• fruit (fresh, frozen or canned);
• dried fruit;
• fruit in composites (e.g. apple pie);
• fresh fruit juice.

A portion is defined as the conventional 80g of a fruit or vegetable. Since 80g is difficult to visualise, survey respondents were asked to describe the amount of each fruit or vegetable they consumed using more everyday terms, such as tablespoons, cereal bowls and slices. These everyday measures were then converted to 80g portions prior to analysis. Examples are given in the questionnaire to aid the recall process, for instance, tablespoons of vegetables, cereal bowls full of salad, pieces of medium sized fruit (e.g. apples) or handfuls of small fruits (e.g. raspberries). In spite of this, there may be some variation between participants' interpretation of how much they consumed. The following table shows the definitions of the portion sizes used for each food item included in the survey:

Food item	Portion size
Vegetables (fresh, frozen or canned)	3 tablespoons
Pulses (dried)	3 tablespoons
Salad	1 cereal bowlful
Vegetables in composites, such as vegetable chilli	3 tablespoons
Very large fruit, such as melon	1 average slice
Large fruit, such as grapefruit	Half a fruit
Medium fruit, such as apples	1 fruit
Small fruit, such as plums	2 fruits
Very small fruit, such as blackberries	2 average handfuls
Dried fruit	1 tablespoon
Fruit in composites, such as stewed fruit in apple pie	3 tablespoons
Frozen fruit/canned fruit	3 tablespoons
Fruit juice	1 small glass (150 ml)

Since the 5-a-day recommendation stresses both volume and variety, the number of portions of fruit juice, pulses and dried fruit is capped so that no more than one portion of each can contribute to the total number of portions consumed. Interviewers record full or half portions, but nothing smaller.

6.2.2 Food Insecurity

In 2017 questions on food insecurity were included in the survey for the first time. The three questions are drawn from the Food Insecurity Experience Scale (developed by the UN). In keeping with the administration procedure for the whole scale, the questions are filtered in the survey (with the second and third questions only being asked if the previous is answered 'yes'). The questions are:

During the last 12 months, was there a time when:

You were worried you would run out of food because of a lack of money or other resources?

You ate less that you thought you should because of a lack of money or other resources?

Your household ran out of food because of lack of money of other resources?

Due to their sensitivity, these questions are asked in the adult and young adult self-complete questionnaires.

6.2.3 Measuring vitamin and mineral supplement use

The following question, designed to measure self-administered supplement use, is included in the core interview, for all adults and children from 2015:

At present, are you taking any vitamins, fish oils, iron supplements, calcium, other minerals or anything else to supplement your diet or improve your health, other than those prescribed by your doctor?

For those who answered positively, this was followed by a new question:

Are you currently taking vitamin D supplements, including as part of a multi-vitamin supplement?

Women aged between 16 and 49 were also asked about their use of folic acid with the question:

At present, are you taking any folic acid supplements such as Solgar folic acid, Pregnacare tablets, Sanatogen Pronatal, or Healthy Start, to supplement your diet or improve your health?

6.3 Fruit and Vegetable Consumption

6.3.1 Trends in adult fruit and vegetable consumption since 2003

Adults consumed a mean of 3.3 portions of fruit and vegetables per day in 2017; 1.7 portions per day short of the recommended 5 per day. This level of adult fruit and vegetable consumption is in the upper range of the time series with average consumption among adults having ranged between 3.0-3.3 portions per day since 2003.

In 2017, around one quarter (24%) of adults consumed the recommended five portions of fruit and vegetables on the previous day. This is the highest proportion of adults to meet the 5-a-day recommendation since the trend data started in 2003 (fluctuating between 20-23% between 2003 and 2016) and represents a significant increase on 2016 (20%). A similar pattern was found for both men and women.

One in ten (10%) adults ate no fruit or vegetables on the previous day in 2017. This represents a slight non-significant decrease from 2016 (12%), but is consistent with the fluctuating proportions (9-12%) seen during the time series which has remained relatively stable since 2003.

In 2017 mean fruit and vegetable consumption was higher among women than men. Women consumed an average of 3.5 portions per day compared with 3.2 portions per day for men. This pattern is consistent with previous years in the trend series. Since 2003 women have consistently consumed a greater mean level of fruit and vegetable portions (between 0.1 and 0.4 portions a day higher than among men, see Figure 6A).

In 2017, the proportion of men who ate at least five portions of fruit and vegetables on the previous day was significantly lower than the proportion of women who did so (22% and 26% respectively).

In 2017, 11% of men ate no fruit or vegetables on the previous day, compared with 9% of women. These figures are consistent with the proportions seen across the time series for women (7-9%) and suggest a return to the stable trend seen in men between 2003 and 2014 (10-12%). Figure 6A, Table 6.1

6.3.2 Adult fruit and vegetable consumption in 2017, by age and sex

Unlike in previous survey years, in 2017 there was no significant difference in the mean portions of fruit and vegetable consumption by age among adults. In previous years adults aged 16-24 consumed fewer portions of fruit and vegetables compared with other age groups, however in 2017 the mean portions of fruit and vegetables for this age group was similar to that for other age groups (3.2 among those aged 16-24 and ranging between 3.3-3.5 among all other age groups).

There was also no correlation between age and the likelihood of consuming at least five portions of fruit and vegetables on the previous day for adults in 2017. Similarly the proportions consuming no fruit or vegetables did not vary significantly by age. Similar patterns by age for fruit and vegetable consumption were found for both men and women.

Table 6.2

6.3.3 Trends in child fruit and vegetable consumption since 2008

In 2017 mean daily fruit and vegetable consumption on the previous day among children aged 2-15 was measured at 2.9 portions. This was the highest mean level since the beginning of the time series, with levels having fluctuated between a mean of 2.7 and 2.8 portions on the previous day since 2008.

The mean consumption of fruit and vegetable portions per day was similar for girls (2.9 portions) and boys (2.8 portions) in 2017. The pattern over time was similar for boys and girls. In previous survey years, among boys the mean number of fruit and vegetables consumed per day fluctuated between 2.5 and 2.7 and among girls it fluctuated between 2.7 and 2.9.

The proportion of those aged 2-15 who ate the recommended five portions of fruit and vegetables on the previous day has remained relatively stable over time; sitting at 15% in 2017, having fluctuated between 12% and 15% in previous survey years.

In 2017, 1 in 10 (10%) of those aged 2-15 ate no fruit or vegetables on the previous day. This continues a steady trend observed since 2008, with levels remaining between 9% and 11% apart from in 2015 when the level dropped to 7%. Table 6.3

6.4 Consumption of Vitamin and Mineral Supplements

6.4.1 Adult and child consumption of vitamin and mineral supplements in 2017, by age and sex

In 2017, 29% of adults consumed non-prescribed vitamin or mineral supplements to improve their health with 19% of people consuming a supplement containing vitamin D.

A significantly higher proportion of women (35%) reported taking a vitamin or mineral supplement in 2017, compared with men (24%). Women were also significantly more likely than men to take supplements containing vitamin D (23% compared with 14%).

Vitamin or mineral supplement consumption varied by age but with no clear pattern. Prevalence was highest among those aged 65-74 (37%) and lowest among those aged 16-24 (22%). There was no association between vitamin D consumption and age.

Nearly one in four (24%) children aged 0-15 years took non-prescribed vitamin or mineral supplements in 2017. One in five (20%) consumed a supplement containing vitamin D.

There was no statistically significant difference by sex for vitamin and mineral supplement use among children in 2017.

Supplements containing folic acid were consumed by 7% of women aged 16-49 (this question was restricted to this age group) in 2017 with those aged 25-34 most likely to consume folic acid (14%). Table 6.4

6.4.2 Adult consumption of vitamin and mineral supplements (age-standardised) in 2017, by area deprivation

In 2017, those living in the least deprived areas were more likely to consume vitamin or mineral supplements than those in the most deprived areas (34% in the least deprived quintile decreasing to 24% in the most deprived quintile). This association was evident for both men and women, see Figure 6B.

The findings also show a link between area deprivation and vitamin D consumption. A significantly smaller proportion (15%) of those living in the two most deprived quintiles were taking a supplement containing vitamin D, compared with 18-23% of those in the other three quintiles.

Figure 6B, Table 6.5

6.5 Food Insecurity

6.5.1 Adult food insecurity in 2017, by age and sex

In 2017, 8% of adults said that, at some point in the previous 12 months, they were worried they would run out of food due to a lack of money or resources. Overall 7% of people ate less than they should due to lack of money or other resources and 4% had run out of food due to lack of money or resources in the previous 12 months. It should be noted that the estimates for prevalence of people eating less than they should due to lack of money or resources or running out of food for this reason are population estimates however as the questions were only asked of those that were worried about running out of food this may slightly underestimate prevalence.

Worrying about running out of food, due to a lack of money or resources, in the previous 12 months was significantly associated with age. Food insecurity was more prevalent amongst younger people with 13% of those aged 16-44 stating that they had worried about running out of food, due to a lack of money or resources, in the previous 12 months, compared with 7% among those aged 45-64 and 1% among those aged 65 and over. Similar patterns were found for both men and women.

Eating less due to a lack of money or resources in the last 12 months was also significantly associated with age. The proportion of people eating less was greater among younger age groups with 11% of those aged 16-44 eating less compared with 1% among those aged 65 and over. This pattern was similar for both men and women.

Running out of food was also significantly associated with age. Those aged 16-44 were most likely to have run out of food in the last 12 months (6%) and those aged 65 and over were least likely (<0.5%). A similar pattern was observed for men and women separately. Table 6.6

6.5.2 Adult food insecurity in 2017, by household type

One in five (20%) adults aged 16-64 who lived alone (single adults), and around one in five (21%) single parent adults reported that they worried about running out of food, due to a lack of money or resources, in the previous 12 months. These groups were more likely than other types of household, to state this.

Around one in ten of those in households with at least two adults (large family, small adult and small family) said that they had worried about running out of food, due to a lack of money or resources, in the previous 12 months (11%, 9% and 8% respectively). Among those living in large adult households (comprising 3 or more adults and no children) 6% had worried about running out of food in the previous 12 months.

Household types without children and of an older age demographic were the least likely to report worrying about running out of food. Among single older adult households (comprising of one adult aged 65 and over with no children) 2% reported worrying about running out of food in the previous 12 months and 1% of older smaller families (comprising one adult under 65 and one adult over 65 or two adults aged 65 and over with no children) reported this. The pattern in worrying about running out of food by household type was similar for both men and women, although it should be noted that the base sizes for male single parent households were too small to report.

Single adult households and single parent households were also the most likely to report eating less than they should or running out of food in the last 12 months. 18% of single adult and single parent households ate less than they should (compared with 1-10% prevalence among other household types) and 14% of single adult households and 10% of single parent households reported running out of food (compared with 0-5% prevalence among other household types). Table 6.7

6.5.3 Adult food insecurity (age-standardised) in 2017, by area deprivation

There was a significant association between area deprivation and food insecurity in 2017. Nearly one in five (18%) people living in the most deprived areas reported having been worried about running out of food due to a lack of money or resources in the previous 12 months. This compares with 3% of those living in the least deprived areas. The pattern was similar for men (3% to 19%) and women (4% to 17%).

Similarly, the proportion that reported to have eaten less than they should due to a lack of money or resources significantly increased with area deprivation. In the least deprived areas, 3% of adults ate less compared with 15% in the most deprived areas. This pattern was reflected in both men (3% to 15%) and women (3% to 14%).

Among those in the least deprived areas, 1% had run out of food in the last 12 months. This increased to 10% of people in the most deprived areas. This pattern was similar for both men (1% to 11%) and women (1% to 9%). Figure 6C, Table 6.8