Dr Fiona Bushell discusses the physical, mental and societal aspects of food consumption.

A real understanding of the impact of food on health must take into account the broad definition of health and the interrelationship between the different factors, ie food quality and safety, food production and distribution, and nutrition, including deficiency disease, increased susceptibility to infectious disease and diseases of excess, such as cancer and coronary heart disease (CHD). A multidisciplinary approach is needed with regards to health, food and nutrition if problems are to be effectively identified and corrective measures determined and promoted.1 A term that embodies this broad approach is "food security", which is a goal of the Food and Agriculture Organisation. Its committee on world food security (1996) states that: "Food security means that food is available at all times, that all persons have means of access to it, that it is nutritionally adequate in terms of quantity, quality and variety, and that it is acceptable within the given culture. Only when all these conditions are in place can a population be considered food secure. We aim to achieve a lasting self-reliance at the national and household levels. In order to succeed, our initiatives must be founded on principles of economic viability, equity, broad participation, and the sustainable use of natural resources." The World Bank defines food security as "access by all people at all times to enough food for an active and healthy life."2

PHYSICAL HEALTH
Food impacts on physical health in terms of survival, growth and development. It also has an important role in the ability of the body to fight disease. There is a link between diet and disease because of the importance of nutrition to the immune system and a poor diet leaves people at risk from infections, which in turn have a role in chronic disease and cancer.3 Cancers of the stomach, colon, breast, ovary and prostate have all been linked specifically to diet.4 Obesity is the most important nutritional disease in developed countries, and even in developing countries obesity is increasing at an alarming rate. Obesity is a major risk factor for CHD and there is social discrimination against the obese, with psychological and social penalties.5 Food intolerance and food insensitivity are unpleasant reactions to food which are not psychologically based but may have a metabolic, pharmacological or immunopatholgical basis. In food allergy or food hypersensitivity there is an abnormal immunological reaction to food.5 Labelling is not easy to understand for those trying to avoid certain additives or proteins, eg azodyes in children's drinks or gluten.6 Foodborne diseases are widespread and a growing public health problem. It has been reported that in 1998 alone, 2.2m people, including 1.8m children, died from diarrhoel diseases globally. A great proportion of these cases can be attributed to contamination of food and drinking water. Additionally, diarrhoea is a major cause of malnutrition in infants and young children.7 Malnutrition and diarrhoea tend to be found together in poor communities. Malnutrition makes people more susceptible to infections, and infections make it more difficult to obtain, absorb and retain food. Infectious diseases and food intake are the two major causes for malnutrition among children in developing countries and the problem is not just one of food shortage, socio-economic status and parental care have a strong influence.8

MENTAL AND EMOTIONAL HEALTH
Consideration should be given to the importance of nutrition to the developing brain and intellectual potential of the next generation. Diet has an impact on behaviour patterns, appetite, satiety, cognitive development and emotional performance. The role food plays in mental health includes mental retardation, lack of concentration and psychological disorders such as bulimia and anorexia. Psychological reactions to food, or aversions, involve unpleasant bodily reactions caused by emotions associated with food.5 When any adverse reaction is delayed, an association with food may be unsuspected, for example there is evidence that gluten sensitivity without accompanying manifestations of coeliac disease can play a part in causing neurological disease.9 There is evidence for the involvement of food and nutrition in the aetiology of disruptive and possibly also criminal behaviour. Hyperkinesis and learning disabilities have been associated with artificial food flavours and colours and a wide range of foods may be involved in causing attention deficiency and hyperactivity in susceptible children. Serious attention should be given to the relationship between adverse responses to food or nutritional deficiencies and truancy, expulsion from school and anti-social or violent behaviour which may result in criminality.10

SOCIAL AND SOCIETAL HEALTH
Food has enormous social importance and spiritual and cultural significance. It is a central part of celebrations, religious festivals, welcoming of guests and family sharing. Not having access to culturally acceptable, safe, adequate, nutritious food through lack of money, education or geography is a major factor in social exclusion. Government messages about healthy eating repeatedly fail to address cultural and behavioural issues or the problems associated with poverty and access. In most developing countries, there is a tendency in low-income communities to replace traditional foods with processed foods, as these represent a "step up" in their social status. However, processed foods are more expensive and the processing normally leads to a deterioration in nutritional status. Aspirations for a lifestyle are also translated in dietary form. Dietary "burgerisation" is presented as driven by youthful demand, but the link with American obesity is not mentioned. There are also health and ethical concerns regarding the subsidising of exports of wheat grains and meat consumption to food cultures where wheat is foreign and meat a rare luxury. Generally, in the Westernisation of diet, there has been a shift from fresh items to frozen or precooked foods. The British eat less vegetables than any other European country; at least half the amount of France, Spain and Italy. This is significant in the UK's record of food- related ill health. Vegetables and fruit contain many of the protective factors for CHD and cancers. Thus, there is a need to focus on the role of food within culture and give more power to the consumer.2

AN INTEGRATED APPROACH
To live a life without malnutrition is a fundamental human right. The right to adequate food is one of the most cited rights by politicians, but is most neglected and violated in practice.11 In 1996, the World Food Summit set a goal to halve the number of food insecure people by 2015. Previous goals have not been achieved because of institutional rivalry, and a lack of political leadership and motivation has meant that nutrition is not top priority and does not therefore attract enough resources. Improvements in food security and health require an integrated approach, intersectoral measures and professionals from many disciplines. Investing in nutrition reduces health care costs, reduces the burden of non-communicable diseases, improves productivity and economic growth and promotes education, intellectual capacity and social development.12

Major challenges identified by the Commission on Nutritional Challenges (2000) include growth retardation; stunted growth, which is linked to mental impairment; undernourishment leading to impaired work capacity and lower resistance to infection; anaemia during infancy, causing poor brain development; maternal anaemia associated with high rates of maternal death; subclinical vitamin A deficiency; the fundamental link between maternal and early childhood undernutrition and an increased susceptibility in adult life to non-communicable diseases; overweight and obesity. An investment in preventing foetal undernutrition is a highly effective investment because of its likely reduction of chronic disease in later life.13

Poverty, rather than lack of knowledge, appears to be the definite factor in preventing certain socio-economic groups from selecting a diet conducive to health. The total number of calories per day and percentage of calories obtained from fat in the diet have decreased overall, yet the National Food Survey shows that improvement in such parameters is not well defined in lower income groups. Knowledge of nutritional issues appears to differ marginally between the social groups, but the poverty gap between the richest and poorest groups continues to widen. Low income produces a range of secondary factors which limit dietary choice among poorer families. Lack of disposable income relates not only to the cost of food, but to transport, cooking and food storage facilities. Money to buy food tends to be from what is surplus each month after payment of bills and the mortgage/rent. The availability of cheap, good quality food also depends on geography. Out of town supermarkets are inaccessible to those who cannot afford transport, the elderly and the sick. In 1996, the Child Poverty Action Group estimated that up to 25 per cent of the UK population are living on or below the poverty line. Changes in the availability of cheap, nutritious food may therefore have a profound effect on the health of the nation.14 The wealthy can choose from up to 20,000 items on the hypermarket shelves, drawn from around the world in a brilliant, efficiently run system of production and distribution.

The range of foods people on low income can choose from is itself a meaningful nutrition indicator.2 An integrated approach involves an appreciation of the social factors that influence nutrition and limit the impact of poverty which include the status of women, education and fertility rates, the burden of infectious disease, governmental commitment and primary health infrastructure.12 Deficiency diseases, particularly those of certain vitamins, have throughout the history of mankind, been a major cause of disease and death. Protein-energy malnutrition cannot be considered simply as a nutritional disease. It has a multifactorial aetiology in which poverty, ignorance, poor housing and lack of family planning all interact. Feeding children more protein will not solve the problem.15 Poverty, powerlessness and poor distribution of resources lead to hunger. People need security, education, control and access to resources. The relationship between livelihood and nutritional status is important as people need food for energy to work, and need to work to afford food. But Britain's infant mortality rate - regarded as an indicator of poverty, poor nutrition, low educational standards and low standards of healthcare during pregnancy and childbirth - is the second highest in the EU.16,17 Food habits are often resistant to change because food means more than meeting nutritional needs. People may refuse to eat particular foods or comply with dietary advice for religious or cultural reasons18 and food intake is heavily influenced by many social, cultural and psychological factors.19 Food habits and eating behaviour determine food choice and therefore nutrient intake. They represent the adoption of societal, cultural and religious values that start in infancy continuing into adulthood. Exposure to a range of influences may modify these habits. Religion may be particularly important in determining food acceptability and be associated with particular eating practices or food consumption. Consumption of specific foods or specific methods of food preparation may demonstrate religious faith. Also, adherence to familiar food habits may create feelings of security and stability. Familiarity is one of the most important factors underlying food selection. General health, mood, convenience, sensory appeal, natural content, price, weight control and ethical concerns are also important.20 To tackle food security, base line studies and data are needed to develop policy and prioritise. There is a need to assess problems and perceptions, to appreciate dynamics rather than take a static snap shot, to see how communities operate and identify leaders and work with people for their benefit. Action plans need to be followed up and they should be people-centred, involve responsive participation, be multi-level, partnership-oriented and sustainable. There is a need for access to culturally acceptable, adequate, affordable, healthy food, and the knowledge of how to prepare it and the skills to grow it. Specifically, there should be a greater degree of self-reliance in food production at national and regional level. The globalisation process, driven by Western tastes and marketing, offers challenges to food and public health. The world needs to move away from cheap, export-led food policies towards local production for local use and environmental, consumer and health considerations need to be integrated.2

Dr Fiona Bushell PhD, MSc BSc (Hons) MCIEH, FRSH, MIFST, University of Greenwich.

References

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