Magoosh GRE

The impact of the Food Industry upon Diet-Related Health Problems

| March 24, 2015

1. Introduction

This dissertation will look at the impact the food industry is able to make upon health problems which have been linked with diet. The risks of poor diet are well documented: “treating treating diseases brought on by poor diet costs the NHS £5.8bn, almost as much as it costs to treat smoking and alcohol related diseases combined” (British Heart Foundation [online] 2011) Conversely, a well-balanced and healthy diet has been linked with reduced risk of heart disease, strokes and can also reduce the risk of developing associated conditions (Medline [online] 2011). There is a complex relationship between personal choice, government regulations, advice by public bodies and the food industry, and this relationship will be examined in order to consider how the food industry currently stands on issues of diet and health, and what they might do to improve public health in the future.

1.1 Background to Study

Heart disease is the single biggest cause of death in the UK, responsible for about 94,000 deaths per year. Over 2.5 million people live with Coronary heart disease, with angina the biggest symptom, affecting 2 million. The heart is a muscle which moves blood around the body through a beating action, sending blood to the lungs to pick up oxygen and then around the body. Heart disease happens when the blood supply to the heart is blocked by fatty deposits in the arteries. Coronary heart disease is the term that describes what happens when your heart’s blood supply is blocked or interrupted by a build-up of fatty substances in the coronary arteries. Narrowed arteries cause chest pains, while blocked arteries cause heart attacks (NHS Choices [online] 2011). Heart disease is linked with poor diet, including diets low in fruit and vegetables, high in salt, and high in fats. Saturated fat can lead to higher cholesterol levels, which in turn is linked to higher incidences of heart disease. In addition, trans-fatty acids, found in sweets and processed foods like cake, are also linked to higher cholesterol levels (BBC [online] 2011).
Heart conditions are also linked with obesity and hypertension. Obesity increases the risk of high blood pressure, diabetes and high cholesterol, and this means a greater likelihood of having a heart attack, and research also suggests that obesity alone can increase the risk of heart attack (Bupa [online] 2011). It is thought that obesity may interfere with kidney function, hormonal and nervous systems, which in turn control blood pressure (Wellcome Trust [online] 2011). Heart disease is also linked to high blood pressure (hypertension). Hypertension increases the pressure in the blood vessels, and makes the heart work harder, which can lead the muscle to become thicker, and heart disease to develop. Hypertension also makes thickening of the walls of the blood vessels more pronounced (Medline Plus [online] (2010). Both these conditions can be caused by poor diet.

1.2 Area of Study

The primary focus of the study is upon the impact the food industry can make upon heart disease, but this will also involve looking at related health conditions of obesity and hypertension, linked to poor health and caused by poor diet, but taking into account the complex relationship between people’s personal choices, the industry as a whole, and the body of regulations and advice that exist in the public realm (Food Ethics Council [online] 2011). The extent to which individuals are responsible for their health or to which the wider social and cultural context need to be taken into account, is widely debated, and there seems to have been a move from a view which accentuates individual choice to one in which the context is increasingly important. To some extent, poverty has been linked to poor diet, with concepts of ‘food deserts’ and ‘food poverty’ in recent circulation, but the food industry, it is recognised, also plays a large part in regulating and influencing people’s diet through labelling, advertising, information and particularly the range of food available for consumers. The industry can make an impact in a wide range of ways, by reducing fat content in food (NICE 2011) or by more responsible advertising (UK Faculty of Public Health [online] 2010).

1.3 Problem Statement

Heart disease is seen as a modern disease, almost unknown at the beginning of the 20th century but reaching epidemic proportions by the 1950’s and 1960’s. As medical treatment improved, with communicable diseases coming under control, so people began to suffer more markedly from non-communicable diseases. The change in lifestyle the 20th Century has witnessed with less mobility, easier access to ‘fast’ foods and more disposable income has also played a part. While heart disease and the related conditions of obesity and hypertension are seen as diseases of the Western world, as developing countries change their lifestyles they are beginning to be an issue elsewhere. It is therefore necessary to consider how incidences of heart disease and related conditions can be reduced. The link to diet (as well as a connection to smoking and exercise levels) has been proved, so one approach to controlling the condition is to understand how people can be persuaded to have a more beneficial diet. While the relationship between what we eat and society, culture and socio-demographics is complicated, it is also likely that the food industry has a vital role to play. By understanding the relationship of food manufacturers and retailers to diet, this study aims to suggest ways to improve the nation’s health.

1.4 Research Objective

The objective of this research study can be stated as follows:
To understand the role the food industry play in influencing diet, and therefore in health problems (heart disease and related conditions), and discover if the industry can do more to prevent such problems.

1.5 Structure of Dissertation

The dissertation will take the form of an extended review of the literature on this area. First, a short methodology section will explain the methods used in the study. The literature review will first look at the relevant background, discussing current awareness about the nature of heart disease and its relationship to related health conditions. Then, the influence of legislation, recommendation by public bodies, individual choice and the food industry will be discussed. Subsequently, the role played by the food industry will be considered in more detail, looking both at reactive changes in food content and labelling, and the research, development and promotion of ‘functional foods’, foods designed to have a positive impact on health. Finally, ways in which the food industry might improve on its current performance in public health will be considered.

2. Project Aims and Objectives / Methodology
2.1 Research Question / Aims

The study’s main objective is to investigate whether the UK food industry could do more to combat diet-related conditions, particularly heart disease and the associated problems of obesity and hypertension. This suggests a number of research questions:
• What is the current incidence of heart disease, what are its causes, and how does it relate to obesity and hypertension
• To what extent does diet play a role in causing heart disease? (What foods are associated with causing it? What foods are argued to prevent/cure it?). What is the role of other factors such as personal choice and government recommendations and policy?
• What role does the food industry in regards to heart disease, hypertension and obesity? (Foods produced, advertising, industry regulation, government regulation).
• Could the food industry do more, either by reducing output of foods associated with a poor diet, or by promoting foods such as those rich in omega-3, to reduce the incidence of heart disease and associated conditions?

2.2 Research Philosophy / Approach / Strategy

The study takes a broadly positivist approach, assuming that reality is objective and knowable, and that the researcher’s task is to investigate clearly defined research objectives and questions by testing them against reality, using deductive methods and a rational approach (Yanow and Schwartz-Shea 2006). It rejects an interpretivist approach which suggests that reality is subjective, and which concentrates on textual analysis from a few human subjects in order to uncover the richness and depth of lived experience (Williams 2000).

2.3 Data Collection Methods

This study is concerned with secondary data, information obtained from already-published sources. Secondary data is contrasted with primary data, collected through research studies designed for the occasion (Babbie 2010). In this case it was felt there is such a body of secondary sources that a primary study was not necessary. Rather, this study aims to investigate themes regarding food industry and health in order to draw new conclusions and make recommendations for future practice. Data was sourced through the author’s university library and online, making use of specialist databases and reports, academic journals and relevant text books. Online searches made use of keywords to narrow down the range of material, including terms such as ‘heart disease’ ‘obesity’ ‘public health’ ‘food industry’ ‘functional foods’ ‘diet’ alone and in combination.

2.4 Ethical Issues / Limitations

As the study did not involve human subjects, there was no need to seek consent nor consider ethical responsibility to them. However, the researcher aimed to conduct herself ethically during the study by ensuring all references were accurate, citing sources used, and attempting to produce a true and accurate picture of the subject under investigation.

3. Literature Review
3.1 The current state of health in the developed world, and the incidence of heart disease

This section looks at the occurrence of heart disease and related conditions both in the UK and worldwide, and provides an overview of the physiological processes involved. Heart disease is shown to be a disease of modern times, with a complex relationship with associated conditions and with causal factors.

3.1.1 The Occurrence and Incidence of Heart Disease

Heart disease is widely seen as a disease of the modern era. At the beginning of the 20th century it was relatively unknown, but by the mid century it was seen as an epidemic, especially in developed nations, primarily due to better health conditions which meant people lived longer. However, some evidence suggests that heart disease has been in existence for a long time, for example paleopathological studies revealing atherosclerosis of arteries in mummies have suggested it was around in Ancient Egypt, and there is also evidence people were aware of it in Medieval times (Faergeman 2003). A vast increase in incidence occurred in the early to mid 20th Century. In the USA, for example, while deaths from heart disease accounted for only 8% of all deaths recorded in 1910, by 1945 this had risen to 45%. This increase coincided with a large decrease in deaths from infectious diseases (Pampel and Pauley 2004). The incidence of heart disease seemed to peak around the 50’s and 60’s, and fall off in later years as the disease was increasingly better understood (Faergeman 2003). Heart disease is more common in men than women, however the rate of the disease in women increases after menopause. A typical patient with chronic heart disease (CHD) is overweight, has a diet high in fat, takes little exercise, has high cholesterol, and displays diabetes and/or raised blood pressure (hypertension) (McConnell 2006). CHD has also been linked to low education levels, poverty and mental health issues including depression (Mackay et al 2004).
Although the increase seems to have reversed since the mid-century (Pampel and Pauley 2004), it’s still the case that in developed countries, heart disease is the single biggest cause of death (Parliamentary Office of Science and Technology, 2005). In the UK, heart disease is the main cause of death for men and women, and represents 20% of male deaths and approximately 12% of female (Office of National Statistics 2006). In total, Coronary Heart Disease (CHD) kills over 90,000 people in the UK every year. The NHS estimate that approximately 2.6 million people in the UK have the condition, with 2 million having angina (chest pain), the main symptom of CHD (NHS Choices [online] 2010). Worldwide, approximately 17 million people are killed by cardiovascular diseases, which accounts for around 33% of all deaths. Rates vary greatly from country to country. Finland’s rate is one of the highest, with China has one of the lowest rates. While developed countries are more affected, as developing countries improve the health of their people and become more industrialised, they also take on Western lifestyles including lack of exercise, smoking and fast food. Traditional diets around the world tend to be more healthy with higher levels of fruit and vegetables, but are being replaced by a diet high in calories, saturated fats and salts. This means that even poorer countries are not immune to ‘Western’ problems associated with diet. Asia, for example, is currently seeing great changes in food consumption leading to increased obesity and rising rates of coronary diseases. Obesity in China, for example, has increased amongst children from 1-5% in 1989 to 12.6% in 1997. Consequently, the problem of heart disease is increasing in the developing world (Senior, [online] 2010). There is also an indication that the phenomenon of globalisation has an impact, as increased travel and communication mean that differences between regions are reduced, as people start to share a common worldview. Other changes linked to globalisation include the transformation of farming, food distribution, shopping and eating outside the home. Such “changing patterns of production and consumption underlie the emergence of non-communicable disease epidemics (Beaglehole and Yach 2003, p. 905). It is clear, therefore, that heart disease and the conditions associated with it are a problem not just for the UK but also worldwide.

3.1.2 Obesity, Hypertension

Obesity and hypertension (high blood pressure) are also associated with heart disease. Obesity is when someone has a body mass index of 30 or more. Today, obesity is caused by a wide variety of issues including lifestyle changes with less physical activity, and eating a poor diet with too many calories (NHS Choices 2010). In 2005, around the world, over 1 billion people were overweight, and 300,000,000 obese, and this figure is predicted to increase to 1.5 billion overweight by 2015 (Yach et al 2010). Within the UK, in 2008, nearly 25% of adults were obese, and about one in seven children. This is also predicted to increase by 2025, when it is estimated that half men and a third women will be obese. Obesity causes heart disease, as well as diabetes, and can thus shorten life expectancy (NHS Choices 2010). The mechanisms by which obesity, high blood pressure and heart disease are linked are complex, and need to be further investigated, but it is thought that hormonal and nervous systems are both involved, for example the rennin-angiotensin-aldosterone hormonal system, which controls blood pressure. It is also thought that obesity impacts on kidney function, which in turn affects blood pressure, with the mass of fat tissue restricting kidney action (Wellcome Trust [online] 2011). A poor diet can lead to obesity, which is directly linked to cardiovascular disease, and conversely eating a healthy diet can help keep weight down and reduce the risk of heart problems. ( [online] 2011). There has been a growing awareness of the role played by lifestyle factors in the development of CHD, and of the link with obesity and the public are increasingly aware of the need to take better care of their heart through diet and other proactive means (Rifkind 1990)

3.1.2 The Nature and Causes of Heart Disease

In order to understand the impact diet can have on CHD, it is necessary to understand a little about heart physiology. The heart’s function is to pump blood around the body. It is a muscle, and beats around 70 times a minute. Blood leaves the heart, goes to the lungs and picks up oxygen. It then goes back to the heart where it is pumped around the body through arteries in a process called circulation. The heart itself is supplied with blood from coronary arteries, blood vessels on its surface. When these become blocked by fatty deposits, the result is an interruption of the blood supply to the heart (NHS Choices [online] 2010). As they gather, the deposits cause the arteries to narrow in a process called ‘atherosclerosis’. Gradually, the vessels become so narrow that they are no longer able to deliver oxygen to the heart. This is particularly notable when the sufferer exerts themselves, leading to angina. If the fatty deposit (atheroma) breaks away, this can lead to a clot forming which in turn deprives the heart of blood and oxygen in a heart attack (British Heart Foundation [online] 2011). The blocking of arteries in CHD, leading to the heart being deprived of blood, and ischemia (infarction) of the cardiac muscle, can be partial or full, temporary or permanent. Depending on how severe the obstruction is, and its type, one of four sets of symptoms can occur in the patient: cardiac chest pain, myocardial infarction (heart attack), sudden cardiac death, or chronic ischemic heart disease (caused by reduced blood supply to the heart) (McConnell 2006).
Coronary Heart Disease is only one of several types of heart disease, and the only one strongly linked to lifestyle factors including diet and exercise. The other types include Rheumatic Heart Disease, damage to the muscle and valves caused by rheumatic fever, a disease carried by bacteria; Congential Heart Disease, problems with the heart which exist from birth and which can include holes in the heart and chamber abnormality (these can be caused by alcohol abuse by pregnant mother, or by use of certain medicines or infection); and also other factors such as tumours, diseases of the heart, or disorders of the heart lining (Mackay et al 2004). The following study is concerned only with CHD, its relationship to diet, and how this is influenced by the food industry.

3.2. The influence of diet on heart problems

Heart disease is clearly linked with a number of conditions as causes, including obesity and hypertension (Reddy and Katan 2004). Most heart problems are caused by the build up of fatty deposits within artery linings, or ‘atheroma’, in turn linked to ‘lifestyle factors’ including smoking, diet and exercise. Other factors have been associated with heart disease. For example, a study in the USA has suggested that social networks, the extent to which an individual feels linked into community and family, play a vital part in both reducing the development of cardiovascular disease, and are also associated with a faster recovery (Steptoe 2010). While a number of such factors exist, and include family history, age and ethnicity (British Heart Foundation [online] 2011), this study will concentrate upon diet as a causal factor. Foods with a negative and positive effect on heart disease will now be discussed.
Fat is one of the main food products associated with CHD, but not all fats are bad. Fats divide into two basic types, the saturated and the unsaturated, and saturated fat is the type which is associated with health problems. Most UK people consume too much saturated fat, which can cause cholesterol levels to increase and hence increase risk of heart problems. Trans fats, found naturally in some foods but at higher levels in processed foods, have also been shown to raise cholesterol levels (NHS [online] 2009). The use of trans fats is particularly high amongst lower income countries, which consume lower cost and heavily processed foods (Perez-Ferrer et al 2010). This is also found in more developed countries where low cost, over processed foods are consumed.
Another problematic ingredient is salt. Research evidence suggests that high salt intake has an impact upon blood pressure. While many countries have an average intake of 9-12 g per day, the recommended level is 5-6 grammes (Feng et al 2011). Countries with higher than average salt intake also have higher levels of blood pressure and higher rates of hypertension. In developed nations, over ¾ of the salt intake is already added to processed food, including bread and cereal products (Young and Swinburn 2002). While high levels of salt can cause high blood pressure and hence lead to heart problems, reducing levels can have a positive effect upon blood pressure (Feng et al 2011). In addition, reducing salt intake by half has been estimated to reduce the occurrence of strokes by 26% (Young and Swinburn 2002). Evidence has also suggested that salt intake has a direct, as well as an indirect impact on hypertrophy in the heart (Feng et al 2011)
Salt and fat are the two main ‘bad’ foods, excessive consumption of which can lead to heart conditions. There are also foods which can make a positive impact on health. For example, while trans fats and saturated fats have been shown to increase the risk of heart disease, and there is evidence that monounsaturated fatty acids and polyunsaturated fatty acids reduce the risk. One type of polyunsaturated fatty acid, Omega-3 fatty acids, are believed to have particularly strong preventative properties (Lewis et al 2009). There has also been a suggestion (Coats and Azyerza 2009) that Chia Seed (Salvia Hispanica L) when fed to pigs can increase the amount of n-3 fatty acid in their meat. There is also evidence that increased eating of fish can reduce rates of CHD (Mozaffarian 2009), as fish has high levels of selenium, a trace element which is thought to protect against heart problems. However, there is an issue regarding fishes’ exposure to mercury, which is a poison (Mozaffarian 2009). In addition, there is limited evidence that increased consumption of whole grains can help prevent hypertension in men. A study of over 40,000 men between 40 and 75 carried out in the UDSA confirmed this link, and further suggested that Bran may play the most important role (Flint et al 2009). Cocoa has also been suggested as a food which can reduce risk of CHD, possibly through activating nitric oxide, and also through antioxidant effect (Corti et al 2009)

3.3 Roles and Responsibility

The above has illustrated that diet has a close relationship with heart disease and the related conditions of hypertension and obesity. However, in order to investigate the extent to which the food industry is responsible for diet choices, it is also necessary to look at the complex relationships of factors that impact on diet. The following will trace the role played by government and other public bodies as well as personal choice, before moving onto the role played by the food industry in the next section.

3.3.1 Government, Public Responsibility and Heart Disease

Food manufacturers’ influence on diet and health needs to be seen in terms of the government and political background to the issue. The growing evidence for the need for prevention of CHD rather than cure has led to new policies being developed in the UK, Europe and the USA. Some suggest increased screening, either of the public as a whole, or screening targeted at individuals (Rifkind 1990). The Labour Government which came to power in 1997 took steps to address differences in health among the UK population. It was noted that CVD and CHD differed greatly across demographic groups, with unskilled, lower income groups and people from South Asia having incidences of CHD three times higher than the population as a whole. There is also a geographical division with northern parts of the UK suffering higher levels. Health equalities such as these were a key target for the Government, with a 2001 announcement aimed to address the difference in life expectancy across different demographic groups in the UK (Department of Health 2004). This was followed by a number of new recommendations and reports at regular intervals during the governments office. In 2002 a target for national health inequalities was set, aiming to reduce health inequalities by 10% by 2010, with a re-affirmation in 2007. A report by the Healthcare Commission in 2008 ‘Are we Choosing Health’ (Audit Commission 2008) monitored the extent to which policy had resulted in improved programme delivery and impact on health inequalities, finding that improvements were not uniform. Reducing health inequalities was also integrated into the NHS Operating Framework for 2009-10. Against this background, which emphasised the wider cultural and social situation in which disease occurs, the government also issued reports and recommendations about CHD and related conditions (Department of Health 2008). In 2000, they published the ‘National Service Framework for Coronary Heart Disease’, which set a target of reducing mortality rates by 40% as well as reducing inequalities in health. This has been successful, with a reduction in deaths from CVD and CHD since 1999, ascribed primarily to a reduction in smoking rates and in cholesterol levels, the last influenced by higher prescribing of statins.
In 2010 the National Institute for Clinical Excellence (NICE) published recommendations designed to promote action across a wide range of UK bodies including the Department of Health, government advisors, related government departments including the Department for Education, the Food Standards Agency, Research organisations and the Advertising Standards Authority as well as food manufacturers. These recommendations highlighted food products linked with increased risk of CHD, and suggests actions that would improve outcomes. For example in order to reduce consumption of salt, they recommended working with food manufacturers to reduce content in food, protect children under 11, improve labelling and monitor salt levels in foods. They also suggest that manufacturers and caters can take an active role in reducing saturated fats, that costs of foods with lower levels of fats could be reduced and that government could work in partnership with industry to promote lower fat milk products for children. In addition, NICE make a number of further suggestions to improve health, including protecting children under 16 from marketing through industry agreements and restrictions on food advertising, improve labelling to ensure it is placed on the front of the pack and indicates through a colour system the risk to health (NICE 2010).
Currently, the NHS highlight the extent to which environment influences personal choices about diet and lifestyle, and hence the need to create an environment which helps people make better choices. In 2010, a White Paper ‘Healthy Lives, Healthy People’, set out the new government’s long-term strategy for public health, based around the idea of a ‘wellness’ service, and seemingly a continuation to notions first developed by the proceeding Government, with an emphasis on social background to health, empowering people to make best decisions and support for early years (DOH 2010). However, they also involve the private sector in creating this environment. The ‘Public Health Responsibility Deal’ encourages partners in the private sector to recognise the role they play in health, and encourages them to enable people to improve their diet (DOH 2011a). The Government have also carried out a number of consultations includes ones on commissioning and funding public health, regulation of professionals and transparency of outcomes (DOH 2010). There are also a number of guidelines on nutrition (DOH 2011b), also building on work done by the Labour government. Recognising the impact of diet on health, and that consumption of saturated fats and sugar is too high, they support a ‘whole diet’ approach, seeking independent advice and working in partnership with other public bodies and the food industry, to build upon recommendations set out in the 2010 White Paper.
Regulations and recommendations are not confined to the UK alone (Sims 1990). Currently, most of the legislation which affects the food industry in the UK derives from the EU. Manufacturers’ claims for food are also shaped by European regulations (Lalor et al 2011). A 2007 White Paper (EU 2007) sets out an approach to preventative healthcare based around diet and exercise in order to reduce obesity and diseases such as CHD. Not only in the UK but in Europe generally levels of obesity and preventable disease have risen, particularly in children, and due to a combination of bad diet and reduced exercise. Again, a multiple stakeholder approach is suggested, working at different levels from the local to the Europe-wide with a consistent approach. However, the White Paper (EU 2007) suggest the need for individuals to take ultimate responsibility, which is somewhat at odds with current UK policy, although they do acknowledge the great inequalities across social and economic groups regarding health by looking for root causes of health problems. They also additionally stress the need for the provision of information, and making sure policies fit together, as well as promoting stakeholder and partnership approaches.
Regulations and suggestions also exist outside Europe. The World Health Organisation suggested in 2003 a number of ways to encourage better decisions about food and therefore reduce the risk of a number of diseases (World Health Organisation 2003). Currently, they make diet one of their priorities for public health, acknowledging the links between an unhealthy diet (as well as lack of exercise) and cardiovascular diseases. In 2004 they adopted the Global Strategy on Diet, Physical Activity and Health, which makes recommendations for member countries and other bodies including the private sector about promoting healthy diet. These recommendations are in tune with UK recommendations, in that they suggest limiting intake of saturated fats, sugar and salt. They also suggest that certain foodstuffs, including unsaturated fats, fruits and vegetables and fibre, should be eaten in bigger quantities. Just as in the UK, a ‘population-based, multi-sectoral, multi-disciplinary, and culturally relevant approach’ is suggested (WHO 2010). Strategies for decreasing salt intake for example include setting up information exchange forums for multiple stakeholders, “creating environments which enable the reduction of sodium intake” (to include education and intervention in the food industry), and monitoring the populations intake of salt. They also propose a framework for effective monitoring of diet and disease prevention, which involves member states developing their own plans for reducing disease, to include promotion of interventions, monitoring at local and national level, improvement of data collection, monitor the impact of socio-economic group on CHD and other non-transferable diseases (WHO 2008).
Broadly, the UK perspective seems to be confirmed by both European and worldwide suggestions, although the UK seems currently to place less emphasis upon individual choice, and more upon wider issues. The tension between individual choice and cultural and social issues will be explored briefly in the next section.

3.3.1 The Role of Choice and the Individual

Overall, it is clear that government play a central role in both education of consumers about food choices, and making sure food manufacturers and retailers follow guidelines on food products. However, there is also an ongoing debate about the role of personal responsibility and choice. The more that it is accepted that an individual is ultimately responsible for his or her own health and the choices he or she makes in support of this, the less the food industry, amongst others, need take responsibility for public health. During the early and mid years of the last Labour government, choice was seen as an ideal to strive for, and health provision was seen on a development from a limited set of choices at the point at which the NHS was founded, through a gradual recognition of people as consumers of health services in the 1970’s and 80’s, with an increased emphasis on providing information to NHS users, to the 1990’s and early years of the 21st century, when patients were offered more say in the nature of their treatments and alternative providers (NHS 2009). In 2003, for example, the White Paper ‘Building on the Best: Choice Responsiveness and Equity in the NHS’, promoted the idea that health provision should be built around the notion of choice, extended from being able to make choices about providers of health services to the notion that an individual is best equipped to make the decisions about his or her own health that will help achieve a reduction in heart disease and other chronic conditions. Hand in hand with this approach was the idea that if people have adequate information about the options, for example what consuming too much of the wrong sort of fat or salt does to the body, then they will make choices which help them be healthier (Department of Health 2003). 2007 saw the launch of a new website with a wide range of content designed to inform and educate: ‘NHS Choices’, designed to empower the public to be more involved in their own health (NHS 2009). However, this emphasis gave way to a realisation that making choices about health is more complicated than this, and involves a complex networks of factors. For example, the British Heart foundation, while acknowledging the need for patients to be provided with information to allow them to make informed decisions, point out that informed choice involves a number of other factors: people need to have the confidence to exercise choice, and may need support to make the best choice for them, particularly if they are from vulnerable groups. Others may never have the skills to make the best choices, and will always need the help of professionals. In addition, the ability to act on choices made is influenced by other factors including income and education level. They also suggest that an emphasis on choice may undermine the provision of ‘joined up’ services (British Heart Foundation [online] 2010). In addition, there has been increasing awareness of problems posed by ‘food poverty’ and ‘food deserts’. Food poverty is associated with people from lower income groups, whereby they lack access to food which are beneficial for the health, and tend to chose foods which are bad for them. A link has been made between levels of poverty and poor diet, and consequently poorer people suffer from more diet related diseases. People with lower incomes typically eat fewer fruit and vegetables, and consumer higher levels of fast food and processed food with more salt and saturated fats (Faculty of Public Health 2005). Poverty of this kind is linked with the notion of ‘food deserts’, or local areas where better quality food is hard to source (Acheson 1998). Researchers, for example Pearson et al (2005) have traced a relationship between access to supermarkets either within walkable distance or through accessible transport, prices of fruit and vegetables and diet, finding that people with lower income tend to live in such ‘deserts’. Recognition of the existence of food poverty and food deserts mean that an individualistic focus on choice and education is not sufficient to improve diet and reduce heart disease. There is a need to “change the ‘food environment’ – that is, accessibility, affordability, culture – in which people live” (Faculty of Public Health 2005, p. 1).

3.4 The Food Industry Role

The relationship between individual choice and wider issues is complex, however the above has hinted that it is not just a matter of government on the one hand and personal choice on the other. The food industry also has influence in the area, and can make both reactive and proactive contributions to the health, perhaps controlled by legislation, through a desire to appeal to customers, or under the influence of research and recommendations. This section looks at the role played by the food industry in contributing to health. The regulations under which they operate are briefly discussed, and look at the different ways in which manufacturers of food and other bodies might influence diet, including supply of information about products, food advertising, labelling and pricing, and government policies on food, education and industry standards (Hawkes et al 2010). The relationship between manufacturers and legislation and guidelines will also be considered. This section will also look at the extent to which the food industry should take responsibility, and particularly at the relationship played by personal choice.
This section will also look at specific products, including products which are linked with obesity and heart disease, such as foods high in trans-fats and salt. The section will also look at products which the food industry claim can help with heart disease, for example Omega 3 fatty acid. It has been claimed that a diet rich in omega-3 fatty acids is linked to reduced rates of heart disease in both men and women (Hu et al 2002). Over the last 100 years or so, Western diets have changed to include much less omega 3 fatty acids, found in fish oils. In Japan, the people of Kohama Island have the longest life expectancy worldwide, and lowest rates of heart disease, and also have high concentrations of omega 3 (Simopoulos, 1999).

3.4.1 Regulatory Context

A number of regulations in the UK impact upon foods and what can be claimed for them. UK Law states that consumable products can be foods or medicines, but not both. Food products are governed by the Food Safety Act (1990) and the Food Labelling Regulations (1996). Medicinal claims cannot be made for foods, and claims about health benefit must be couched in suitable terms. The Joint Health Claims Initiative, a collaboration between the Food and Drink Federation, British Retail Consortium, Consumer Association and Local Authorities was established in 1997 and developed a code of practice on health claims. A Food Standards Agency report in 2002 showed that people were still confused over manufacturers’ claims for food products, however, and reiterated that there was a need for clear and accurate labelling and information. (Fenn 2010)

3.4.2 The Role of the Food Industry

The food and drink industry seem to feel that they are being proactive in concerns for health and wellbeing. In a Food and Drink Federation Symposium Report, they report that ‘healthy eating options’ show no sign of being less attractive to consumers despite the recent recession, and also report that levels of salt and saturated fat in their members’ products show a decrease over the past 5 years. Their approach centres around informing the customer, rather than the socially and culturally aware approach of regulatory bodies, and they highlight the importance of clear labelling to the front of the pack, with concerns about how to get people to make better use of labels. However, there is also some acknowledgement of the use of for example workplace interventions and social support, and a commitment to partnering with government and regulatory bodies (Leech, 2011). As such, it would seem that the food industry see themselves as a beneficial force for public health. This is, to some extent, confirmed by action. The International Food and Beverage Alliance was set up in 2008 to respond to suggestions made by the WHO about nutrition and diet, involving large manufacturers of food including Ferrero, Kraft, Kellogg’s, Mars, Nestle, Unilever and PepsiCo. Together the 10 manufacturers represent 80% of global spend on food advertising, and have reach over more than 200 countries. This therefore marks a notable attempt to address issues of diet and health worldwide. PepsiCo, for example, have extended efforts to look at non-financial matters since 2007, in order to move to an approach which embraces different stakeholders and aims for sustainability. One of 11 goals they announced in 2010 was helping people live more healthily. This translated into changes in product formulations, changes to marketing and changes to the way information is provided about products. This was done by reference to guidelines from the WHO, including ‘nutrients to limit’ and ‘food groups to encourage’ (Yach et al 2010). However, there are many who criticise the role played by the food industry, for example the growth of fast food restaurants has been linked to obesity (Currie et al 2009), and the industry in general to the rise in non-communicable diseases (Beaglehole and Yach 2003). It has been suggested that manufacturers exploit a physical addiction to ‘fast’ food meaning that many find it hard to control what they eat, and have stronger cravings for sugary and processed food than that average. Manufacturers have, until recently, fed this hunger for low cost, highly processed food amongst consumers through a clever use of product design and visual advertising (Kessler 2011). Others have suggested that the industry have co-opted public bodies to provide a rationale and context for their products, perhaps by hiring academics or financing research. Dixon et al (2004) suggest various strategies used by the food industry in Australia, including sponsoring research into nutrition (For example Kellogg Australia’s ‘Facts for Life’ initiative in 1998), attempting to portray opposition to their products in a negative way, and using apparently neutral organisations as a ‘front’ for example to sponsor seminars. The industry also makes careful use of the media, particularly women’s magazines, to promote their products as key to healthy eating and prevention of disease. They can also have an undue influence on the regulatory structure which governs their products through lobbying or taking part in committees (Dixon et al 2004). In their defence, because the production and supply of food is a complex matter involving multiple interested parties, the food industry can be hampered in attempts to alter its products. Science, supply chains, farming, food retailers, government and other public bodies all play a role in determining the current market for food products. In addition, environmental conditions outside human control may impact upon which and how many crops are available, with cold weather in China leading to smaller harvests of soybean (Yach et al 2010).

3.4.3 Reactive Responses by the Food Industry

A number of reactive approaches have been taken by the food industry, as a result of action by government bodies requiring labelling of content for example. For example, in the late 90’s in Australia, a programme instigated by the National Heart Foundation called ‘Pick the Tick’ led to manufacturers reducing the salt content of processed food substantially. This programme followed government reports recommending the lowering of salt intake, which also recommended that manufacturers could be instrumental in this. Guidelines on salt intake were first introduced in 1979 and revised subsequently. Reports in the late 90’s that cereals were particularly prone to salt addition led to industry players such as Kellogg developing new strategies for nutrition and product development, as well as introducing new ways of communicating with the public (Williams et al 2003). In addition, manufacturers have responded to research recommending a low fat diet by increasing production of foods low in fat (La Berge, 2008; Brook and Rifkind 1988).
Salt, it has been shown, is one of the main issues for health and diet, and manufacturers have a history of loading food with excess salt assuming it answers consumer demand. More recently, and in response to legislation and guidelines, they have made efforts to benefit health. There are several ways in which the food industry can reduce salt intake. They can make and market low salt foods, although these tend to be rejected by the consumer due to higher costs and perceptions of poor taste (Engstrom et al 1997). They can also make sure foods are clearly labelled for salt content, or they could gradually lower the salt content of food over time, allowing consumers to adapt to the different taste (Young and Swinburn 2002).

3.4.4 Proactive Responses by the Food Industry

In addition to reactive measures, however, there is an increasing trend for manufacturers to market their products as directly beneficial to health, primarily through researching and developing products containing substances which are shown to have preventative or curative impact on disease. These products have become known as ‘functional’ foods, which offer a way to promote health through consuming them (Sun-Waterhouse 2011). A food can be defined as functional “if it is satisfactorily demonstrated to affect beneficially one or more target functions in the body, beyond adequate nutritional effects … ” (Diplock et al., 1999). Functional foods were first introduced in Japan by the food industry there (No-Seong Kwak and Jukes 2001). In 1990 Japanese government approved the commercial use of functional foods or ‘Foods for Specified Health Use’. They were introduced into the USA during the 1990’s following a period of research into buyers attitudes (Markovina et al 2011). Although the term is used less frequently in Europe, and in the USA there is no agreed definition, the market for these foods is increasing in all developed countries, Functional foods have a potential both to improve public health and to offer increased profits for food manufacturers. So far industry has spent millions researching and developing such products (Lalor and Wall 2011). The first functional foods on the market were ones to which vitamin C had been added, later ones included calcium added, whole grain food, omega-3 fatty acids and phytosterols, designed to address an increasing consumer motivation to take better care of their health (Christidis et al 2011). A number of major manufacturers have launched these products: Unilever, for example, are embracing the turn to functional foods as well as aiming to reduce fat and salt content of the existing range. In the 90’s they removed trans-fats from their European range of margarines and butter substitutes, and In 2006 they announced a move to more active promotion of beneficial foods, believing that the food industry in general suffer from a backlash against producers of over processed goods. They state that manufactures lead the way in shaping consumer demand for ‘good’ foods, and have invested heavily in researching and developing new functional foods (Gill 2008).
There are a number of different functional foods. One is soy, which research has shown to have anti-carcinogenic and antiatherogenic properties. A Japanese study, for example, supports the idea that soy can protect against heart disease, due to the high amounts of isoflavones it possesses (Nagata 2000). Another is fibre: research has shown that oat fibre can lower plasma, and rice and barley fibre may lower cholesterol, for example 5 large studies in USA, Norway and Finland showed that people consuming whole grain cereals have lower rates of CHD (Reddy and Katan 2004). Anti-oxidents can also be added to foods, these include Vitamin E isomer and Vitamin C, and research has suggested that increased consumption of these can help prevent disorders of the heart arteries (Reddy and Katan 2004). Flavoids, occuring naturally in some foods including tea and apples, have been suggested to lower rates of heart disease (Reddy and Katan 2004)
Functional foods have proved popular. Within the UK, the market for functional foods grew by nearly 10% in the year to October 2009, with an estimated value of £1.46bn. Available products include fortified breakfast cereals, probiotic yoghurt, soya milk and cholesterol-reducing spreads. There has been some change in the market, with some products confusing customers, and others having doubts about product safety or efficacy. While the recession has had a slowing effect on the sales of functional foods, with a turn to price-consciousness and value, it is predicted that sales will grow over the next 5 years, although new EU regulations are likely to restrict new product launching on the market. In the UK, as elsewhere, the market for functional foods is driven by a new concern amongst the population about obesity, and also an ageing population keen to secure a healthy old age. The most popular functional food is fortified cereal, closely followed by fortified bread (Fenn 2010).
However, functional foods are heavily regulated. The marketing of functional foods in the UK is regulated by EU legislation, and manufacturers need to show evidence that the food is safe to the Independent Advisory Committee on Novel Foods and Processes, and also obtain approval from the UK government before launching new products. Additionally in 2006 the EU issued new regulations ensuring that some functional foods should be assessed scientifically (Fenn 2010). Different regulatory environments exist in different countries: Lalor and Wall (2011) compared USA, Japan and Europe and found. In Japan, a definition and policy, was quickly introduced, as well as regulatory bodies. Products have to pass a vigorous application procedure based on evidence, safety and knowledge about constituents of the product to be approved as one or other type of functional food. In the USA the Nutrition Labelling and Education Act passed in 1990 gave the Food and Drink Administration the right to demand correct labelling of products and to ensure that claims about food products were acceptable. They have authorised a number of health claims including links between saturated fat and cholesterol and heart disease and between soy proteins and plant sterol/stanol esters and heart disease. Companies have to apply to the FDA for permission to manufacture products, and validate claims through scientific evidence, setting out the link with health benefits clearly (Lalor and Wall 2011)

3.5. The Future: Functional Foods and the Food Industry

Overall, it is clear that food manufacturers have a role to play in improving health. While government legislation, recommendations and intervention programmes play a part, and while personal choice also makes some impact, manufacturers have an unequalled opportunity to influence health and diet through advertising, research and development and product refinement. They can either be reactive, simply acting in accordance with UK and Europe-wide regulations on labelling, advertising and food content, or they can take a proactive role. One key way they can be proactive is through the development of ‘functional foods’, but they can also make a difference by taking a collaborative, partnership approach to food production and promotion. This section will discuss two ways in which they might build upon what has been achieved so far, first by taking note of consumer responses to functional foods, and second by embracing a partnership approach.

3.5.1 Research into Consumer Responses to Functional Foods

Research studies into consumer responses to functional foods can suggest ways in which manufacturers can help benefit public health in the future. There already exists substantial research into this, generating some insights.
Trust is a key issue. For example, Hall et al (2011) suggest that people have a more positive response to publicly sponsored information and advertising about food than that sponsored by the food industry, and that people with a more positive response are correspondingly more likely to take positive steps towards health. Siegrist et al (2008) confirms that trust is an issue important to consumers, and this theme is expanded on by Christidis et al (2011), who also confirm that consumers prefer to receive information from sources perceived as trustworthy, that is people in health care professions. They are less influenced by food packaging and labelling. While they find labelling useful, they also view the claims made by manufacturers on the labels with suspicion, and can find overly scientific explanation confusing. Consumers particularly doubt manufacturers claims when they have a knowledge of nutrition themselves (Christidis et al 2011). A cross-Europe study by the European Food Information Council (1996) also suggests that healthcare professionals are the preferred source of information about healthy living, trusted by 80% of those interviewed. There is therefore a need to either improve the public image of manufacturers in regards to the claims they make about their foods, to improve trust, or to create transparent links with public bodies to bolster public reassurance. Manufacturers could boost confidence by turning away from processed foods, and perhaps funding community initiatives in exercise and healthy diet to improve their public image.
Rather more ambiguous is customer attitudes towards functional foods in general. Attitudes are complex, and customers feelings are not a simple reaction to being given information about the food, but are a mixture of ideas about the nutritional value of food, the health benefits and drawbacks, psychological aspects and perceived value and cultural acceptability. Cultural, educational, economic factors and food availability are all influential on dietary behaviour (Lalor et al 2011). Understanding the health benefits is one matter, seeing the benefits as relevant to their own situation is another. Research has identified a number of associations made with purchasing such food including a need for discipline and control in monitoring ones diet as well as a (perhaps contradictory) belief that one needs to listen to ones inner bodily needs (Niva 2007). Some people are simply not interested in the idea of functional foods (Korzen-Bohr and O’Doherty Jensen (2006). Studies around Europe differ regarding the levels of awareness they find of health promoting foods. A Croatian study of young people found 40% were aware of the idea, and 27% purchased such foods (Markovina et al 2001), while a Greek study suggested 1/3 of consumers were aware of the term ‘functional food’ (Christidis et al 2011). Others have found that some claims about functional foods are believed more than others, and some products are more respected than others (Lalor et al 2001). Korzen Bohr and O’Doherty Jensen (2006) suggest that functional foods suffer as they are not given a physically distinct area in supermarkets, but are placed with other examples of that product type (all cereals are placed together for example).
The complexity of attitudes towards these foods, and the relative lack of awareness of what they are suggests that manufacturers might do more to promote awareness of the products. Currently, manufacturers advertise individual functional foods, but a campaign to add weight to the idea of functional foods in general might be useful. They also need to address the cynicism about claims made, and perhaps do more to understand the details of what health and eating well means to consumers.

3.5.2 The Need for Partnership Working

Another area which food manufacturers and retailers might address to increase confidence in functional foods and thus help improve health is by making more links with the public sector and embracing partnership working. While private organisations in the industry have used links with research in a less than honest way, by making a financial contribution to research that supports their products, this has not helped their image with the public. They need to overcome this by working honestly with the public sector and government. As early as 1990 Chapman suggested the need for better frameworks for relationships between government department and the private sector, to ensure that regulations regarding labelling and food standards are better adhered to (Chapman 1990). While labelling has improved a great deal since then, there are still ways to improve partnerships between the sectors. An interest in the benefits of partnership between public and private sector came about during the last Labour government, as people started to recognise that a focus upon individual choice about healthy eating was inadequate, and there was a need to focus on broader cultural and social solutions. It was thought that partnership between sectors could offer an approach to do this. There have been successful UK examples of effective partnerships, for example the ‘Heartbeat Wales’ initiative in conjunction with supermarkets, designed to reduce heart disease by prevention (Dixon et al 2004). Another example from outside the UK is the ‘Pick the Tick’ programme from the National Heart Foundation of New Zealand. This set out to work with the food industry to improve food labelling and deliver increased health through food. Manufacturers could display the ‘tick’ on their products if they met certain criteria for them. The campaign was influential, with over ½ of shoppers making choices based on the ‘Tick’ (Young and Swinburn 2002).
The complex nature of food production in the modern world and the relationship of food to health, means that simple solutions are not possible, and interaction between all parties is necessary. The last few years have seen increasing acknowledgement of this, with the Global Agenda Council at the World Economic Forum in November 2009 suggesting the need for an ‘Action Coalitiion’ to promote cohesive policy for health globally, working with the World Health Organisations Non-communicable Disease Network. While the food industry seems to be taking steps towards committing to partnerships, with new initiatives in place to work together to set out standards for labelling, marketing to children and product formulation, there is still work to be done, particularly in the area of monitoring partnership work (Yach et al 2010)

4. Conclusion

The above has examined the nature of heart disease in the modern world, with particular reference to the UK. It has been shown that heart disease was largely unknown before the 20th century, but by the 1950’s had reached epidemic proportions. The causes of heart disease and the related conditions of hypertension and obesity are complex, but it is clear that diet plays an important role. This study has set out the areas of responsibility for managing public health in respect to these conditions, and has suggested that despite government and personal choice having a role, food manufacturers and retailers also have an important role to play. The food industry has made many advances by reacting to legislation and recommendations, for example in the field of food labelling, but can also make a more proactive contribution in the field of functional foods, or foods which help address health problems. While functional foods are growing in popularity, the public has doubts about the trustworthiness of the industry as a whole, and penetration of foods with health giving properties is not high. If the industry addresses consumer concerns and attempts to fully understand the complexities of the way people perceive health, diet and food, they have the potential of contributing more to health. In addition, if they continue to embrace a partnership approach, they can also increase their contribution.
This study took the form of a literature review, and this could be seen as a limitation. It would be useful to carry out further research both amongst consumers and the industry to see what further changes could be made by the industry to contribute further to the nation’s health.

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