17 AUGUST 1985, Page 8


Rigby Anderson on the futility and

danger of the state deciding what people ought to eat

GEORGE'S doctor has referred him to a dietitian. George and the dietitian have a ten-minute interview. George has his name and referral details taken. He is weighed, his weight recorded, explanations are gone into about metric weights because George does not understand these. Then the dieti- tian tries to find out what George is currently eating. This is not easy to estab- lish. George eats lots of different things, at different times and places and in different forms. Details are sought and given about times, weights, thicknesses, costs, brands, and George's family and work. There are misunderstandings because George and the dietitian do not categorise food in the same way. Not only does George not understand about different food groups as classified by nutritionists — carbohydrates, proteins etc — he doesn't mean the same thing as the dietitian when he says 'starch' nor, it turns out, do they use cooking language such as 'grill' and 'roast' in the same way. There is no time to find out all that George eats on all occasions and that is a pity because it varies a lot. The sheer chaotic variety of eating is the dominant impression I gained studying interviews like that of George in a busy city hospital.

Much of the time that is available is taken up with George talking about his collar size and recent purchase of shirts, his holidays, what happens when his wife's sister comes over every other Saturday but not in July and the extraordinary permuta- tions of his shifts at work and their effect on the consumption of sandwiches. The dietitian encounters and puts up with all this because she depends on George to tell her what he eats and the only way George can do it is by telling her about his wife's sister as well. From time to time the dietitian suspects George is not telling the whole truth (about his food; she is indiffe- rent to the truth of the statements about his wife's sister) and she ventures a question to see if her suspicions are correct.

Then the dietitian gives George a diet, explains it and sees if George understands. He does and he doesn't. Once again confusion arises not only because they classify foods differently but because George is not used to interviews and spends much of the time learning and not learning what sort of answers are needed. The dietitian patiently seeks examples he will understand only to find at last that he does not understand the principle they are designed to exemplify — George has been saying he understands very well because that is what he thinks is expected of him.

George is asked if he has any questions, a date is fixed for the next appointment and he leaves. Just before he leaves George asks four questions in quick succes- sion which show he has completely mis- understood much of the advice. Repairs are hastily effected and George leaves. His interview consisted of 157 utterances, many of necessity unplanned, the dietitian unable to frame her advice until George has (mis-) informed her about his food and then having to give it instantly. The dieti- tian works out what to say next as George is speaking, sometimes after she has already started a sentence. The longest pause between two utterances is two seconds.

The hard-working dietitians who con- duct these interviews have no illusion about their effect. They know many Georges will not follow advice or even understand it. They realise that they them- selves often do not get an accurate picture of George's current eating habits. It's a hit and miss affair.

It is difficult to persuade someone to alter his diet, difficult to learn what he does and difficult to explain what he should do even when he is movitated because ill, even when the diet he should follow can be medically established and even when the obstacles to its adherence can be identi- fied. Dietitians would be the first to admit that, in this sense, dietetics is not a very successful business. Most resign them- selves to more hard work and few rewards.

Politicised nutritionists and, worse, politicians who take up nutrition are quite the opposite. Setbacks to them are not occasions for resolutions to continue work- ing hard but modestly, but an excuse to aggrandise the enterprise. If it's difficult to get one patient to change his diet, let's try and persuade the whole population. If it's tricky to find the right diet for George after an interview, let's generalise about the diet everyone ought to be following on the basis of no detailed information about indi- viduals' diets at all. If George who is ill and highly motivated to change won't, let's have state propaganda to convince the healthy unmotivated population to change. If it's impossible to plan an interview five minutes ahead, let's plan for the popula- tion 15 years ahead. Fuelled by the more extreme ideas (there are some sensible ones) of the National Advisory Committee on Nutri- tion Education (Nacne), the Government's own Committee on Medical Aspects of Food Policy (Coma) and, most recent, the Labour Party's Food Policy — A Priority for Labour, a vociferous lobby for Food- Leninism is emerging. The Labour paper wants government intervention to force food companies to print lots of nutritional information on food container labels, a health education programme to make us understand what it has forced the com- panies to print on the labels, and surveys to find out how much or little we do under- stand and how much longer the labels will have to be in the future. Following the Nacne report, there were calls for: taxes to be imposed on food products that these Food-Leninists decree are bad for us; advertisements of 'unhealthy products' to be banned; intervention to 'alter' public attitudes (Leninists talk of altering public attitudes as if it were like declaring a bank holiday); state intervention by price and subsidy to ensure that livestock is bred to the size and shape the Leninists decide is good for us (the moo-cows will be on a diet too) and much much more money for the Leninists to dream up new regulations all within a state plan.

The barminess afflicts Conservatives as much as Labour: the Government approves of the increasingly uneducational propaganda of the Health Education Council and repeatedly raises its grant. Dr Owen certainly was a fan, and a meeting of the 'Green Alliance' I recently spoke to Was stuffed with paternalistic, centralising bran evangelists dying to force the lower classes to eat muesli and read encyclo- paedic baked bean labels. It appeals not only to the paternalist but to the cost- Cutter: think of the savings to the NHS if we could reduce diet-related disease.

So it's important to rehearse the argu- ments. First, Food-Leninism has nothing to do with modest health education. Of course teachers should find some time during the bloated 15,000 hours of compul- sory schooling to teach principles of nutri- tion. Of course the hard-working dietitians should keep at George. But those are far too modest, though difficult operations for the Leninists. Not only is sensible health, education not Leninism, the Leninists threaten it. If half the money spent on dotty propaganda campaigns was spent helping the dietitians help George, we'd all be better off. The campaigns are far the major part of current health 'education' expenditure.

The Food-Leninists claim that bad eat- ing is a major problem and that they know and agree what, in nutritional terms, is wrong with it and what needs to be done about it. The 'problems' are that we do not have enough information about food and therefore make mistakes; the wicked food Companies deceive us with advertisements and labels and some of us — 15 million according to the Labour document cannot buy healthy food because we are poor. These problems justify the Leninist solutions which fall into two sorts: creating the conditions in which people are encour- aged and able to eat a healthy diet' Coercive meddling with food companies, agriculture and taxes; and providing `adequate information' — propaganda.

`The problem' is neither as sure nor as agreed as the Leninists argue: clinical and laboratory research controls out many of the variables which surround eating in the outside world. Epidemiological research uses many factors, such as cause of death as given on death certificates, notoriously subject to circular influence. The research is pathologically biased: it asks why this sick man died, not how that ten-pint-a-day man managed to live until 90. Embarras- singly little research is direct observation of how people eat; too much is surveys of what people say they eat when asked by surveyors. The rates of risk so emphasised by the Leninists are averages often subject to extreme internal variation. One school at least now argues that what is a danger- ous amount of, say, cholesterol for one man is safe for ten of his friends. Such criticism not only damages the Leninist case in general, it suggests that global campaigns will not identify the smaller `population at risk' and waste money in the time-honoured fashion of an indiscriminate welfare state, failing to help the needy few while inconveniencing the healthy many.

None of which means there is not a nutrition problem. Certainly we can la- ment the disgusting things people eat — I do regularly in my Spectator column. It simply means that we do not know the sorts of things about the problem which justify us talking of a grand solution.

If the nutrition problem is not too precise, the assumptions (for that is what they are) about its social causes are down- right dodgy. It is not clear that we are starved of information about nutrition. There are many books and pamphlets, some selling very well. Various food retail- ers are voluntarily supplying verbose baked bean labels for those who enjoy them. Diet is a frequent and very boring topic of conversation. I'm told it is discus- sed on television. There is simply no need for more undirected pamphlets and chat- ter. It is possible, indeed likely, that specific parts of the population are ill- informed but that is a different matter. Nor is it established that they are ill-informed because they are deprived of information or that the Leninists know, any better than many others who have failed, how to get at them.

It is not established that the wicked food companies manipulate demand by misin- formation. Capitalism is amoral, as happy to make money out of the burgeoning `healthy' foods as out of unhealthy foods, content to exploit whatever a reasonable number of customers demand, including baked bean labels with science on. Diet books and yoghurt have made several fortunes recently, though of course the lower classes insist on having yoghurt which tastes like flavoured ice-cream.

It is not true that poverty, of the sort that 15 million enjoy, makes a healthy diet impossible. The 15 million increasingly choose to spend their wages or state handouts on expensive processed or con- venience foods. Did they make the effort, a healthy diet could be had very cheaply.

And then there is the assumption that these old favourites are the only possible causes. Does the increase in the number of working mothers have nothing to do with the increase in convenience foods? Is the vast increase in single parent families unconnected with instant eating? Are the disgusting and unhealthy snacks beloved of the younger generation not a product of the decline of parental authority along with that of ordered family meals? But I do not hear the Leninists calling for support for the traditional family, fewer incentives for divorce and bastardy and more discipline.

And, even if they could identify the problem and its causes, that would still not justify the solutions they advocate. They do not want more 'information'. It is now a decade since health educators admitted that 'information' alone accomplishes no- thing. They do not want the full scientific ingredients listed on food product labels. They want enough information and in- formation couched and coded in such a way as to help the choices they think are important — this is plainly mere prop- aganda.

As for the differential taxes and adver- tisement bans, would they work in the direction intended and at what cost? In fact the Leninists know nothing about the policies. Insofar as they have expertise it is in nutrition not the social policies designed to implement nutritional reforms. They know something about cholesterol, next to nothing about the cervelles au beurre noir which contain so much of it, even 'less about who eats cervelles, how, why and with what consequences, and nothing ab- out how to stop them.

Digby Anderson is Director of the Social Affairs Unit. He was previously a research fellow in health education at the University of Nottingham.