Publication
Health Education Population Survey (HEPS) 1996-2003
6. Diet
Healthy eating is of particular relevance to health promotion given its implications for cardiovascular disease‚ cancers‚ oral health and the rising levels of childhood obesity. It has also been shown that high consumption of fruit and vegetables is associated with reduced risks of cardiovascular disease and certain cancers (National Forum for Coronary Heart Disease Prevention‚ 1995; World Cancer Research Fund/American Institute for Cancer Research‚ 1997). The current dietary target for fruit and vegetables is to increase the current average intake to at least 400g (five portions) per day by the year 2005 (SODoH‚ 1996). There has been a high level of concerted health education activity across all sectors in Scotland‚ focused on the 5-a-day message during the survey period.
For the purposes of this survey‚ eating fruit and vegetables daily is used as a proxy indicator of a generally healthy diet‚ since good nutrition has been found to be particularly strongly correlated with a high consumption of fruit and vegetables (Blaxter‚ 1990). Additional analyses of the HEPS data shows that respondents consuming fruit and vegetables daily had a healthier diet in terms of eating more complex carbohydrate and fish and less sugar and high-fat foods than other respondents‚ and were more likely to have tried to change their diet in the past year to improve their health.
6.1 Risk behaviour
There has been a significant reduction in dietary risk behaviour over time with improvement in daily fruit and vegetable consumption during the 1996-2003 survey period. In 1996‚ over four in ten respondents did not eat fruit or vegetables daily‚ compared to around three in ten in 2002-2003 (Table 6.1).
This trend is supported by findings from the Scottish Health Survey that showed significant increases in the proportions of respondents eating fresh fruit daily between 1995 and 1998 (Shaw et al‚ 2000). Daily consumption has increased for both men and women and for all social grades since 1996‚ but has not increased for those living in more deprived areas. Men have been consistently less likely to eat fruit and vegetables daily‚ as have those in social grades C2DE and those living in the more deprived areas (DEPCAT 6-7).
The likelihood of daily fruit and vegetable consumption increases with age; younger respondents were least likely to eat fruit and vegetables daily. There have been significant increases in daily fruit and vegetable consumption for most age groups since 1996‚ with the exception of those aged 16-24. Over four in ten of this age group still did not consume fruit and vegetables daily in 2003.
Table 6.1: Percentage not eating fruit and vegetables daily, by sex/age/social grade/DEPCAT
% |
1996 |
1997 |
1998 |
1999 |
2000 |
2001 |
2002 |
2003 |
All |
43 |
36 |
39 |
37 |
– |
33 |
31 |
31 |
Sex |
|
|
|
|
|
|
|
|
Men |
48 |
41 |
44 |
39 |
– |
39 |
40 |
37 |
Women |
39 |
31 |
34 |
35 |
– |
28 |
23 |
25 |
Age |
|
|
|
|
|
|
|
|
16-24 |
44 |
46 |
47 |
57 |
– |
37 |
44 |
42 |
25-34 |
51 |
38 |
52 |
41 |
– |
35 |
36 |
34 |
35-44 |
49 |
35 |
33 |
32 |
– |
34 |
32 |
30 |
45-54 |
41 |
36 |
36 |
34 |
– |
32 |
27 |
26 |
55-64 |
28 |
31 |
33 |
31 |
– |
32 |
22 |
26 |
65-74 |
41 |
25 |
24 |
25 |
– |
28 |
23 |
25 |
Social grade |
|
|
|
|
|
|
|
|
ABC1 |
35 |
26 |
31 |
26 |
– |
21 |
25 |
23 |
C2DE |
49 |
45 |
46 |
47 |
– |
44 |
37 |
38 |
DEPCAT |
|
|
|
|
|
|
|
|
1-2 |
39 |
27 |
26 |
24 |
– |
24 |
20 |
20 |
3-5 |
43 |
35 |
40 |
39 |
– |
38 |
31 |
31 |
6-7 |
47 |
45 |
50 |
48 |
– |
50 |
45 |
43 |
Base: all respondents |
1810 |
1795 |
1794 |
880 |
– |
1757 |
1742 |
1720 |
|
Significant changes (p<0.05) |
This means there is a growing divergence in patterns of daily fruit and vegetable consumption between those living in affluent and deprived areas and between young people (16-24) and older age groups. This is clearly illustrated in Figure 6.1 below.
Figure 6.1: Percentage not eating fruit and vegetables daily by DEPCAT 1996-2003
Base: all respondents
6.2 Protective behaviour
In line with the Scottish dietary targets‚ a key health recommendation over the past few years has been to eat at least five portions of fruit and vegetables a day. When asked how many portions they had eaten the previous day‚ around one in five had consumed the recommended amount in 1996 rising significantly to almost three in ten in 2003 (Table 6.2). This trend of dietary improvement is supported by findings from the Scottish Health Survey (Shaw et al‚ 2000). However‚ Figure 6.2 shows results from the National Food Survey that indicate a decrease in the average consumption of fruit and vegetables per person per week in Scotland between 1997 and 2000 (DEFRA‚ 2001).
Figure 6.2: Consumption of fruit and vegetables in Scotland‚ 1997-2000‚ National Food Survey (grams per person per week)
As shown in Table 6.2‚ women and respondents in social grades AB were more likely than men and those in the lower social grades to have consumed the recommended amount of fruit and vegetables. The percentage of women and those in social grades AB eating the recommended amount increased significantly over the eight years. The evidence for an increase for those in the lower social grades is less clear‚ although the 2003 data suggest a possible increase more recently. Further years’ data are needed to determine if this constitutes a genuine upward trend.
Table 6.2: Percentage eating at least five portions daily by sex/age/social grade/ DEPCAT
% |
1996 |
1997 |
1998 |
1999 |
2000 |
2001 |
2002 |
2003 |
All |
18 |
21 |
22 |
24 |
– |
23 |
28 |
29 |
Sex |
|
|
|
|
|
|
|
|
Men |
14 |
17 |
16 |
22 |
– |
16 |
21 |
21 |
Women |
22 |
25 |
28 |
27 |
– |
29 |
36 |
36 |
Age |
|
|
|
|
|
|
|
|
16-24 |
12 |
15 |
15 |
9 |
– |
15 |
15 |
19 |
25-34 |
12 |
20 |
17 |
20 |
– |
23 |
26 |
28 |
35-44 |
19 |
17 |
22 |
33 |
– |
23 |
30 |
27 |
45-54 |
22 |
24 |
25 |
28 |
– |
26 |
32 |
34 |
55-64 |
27 |
28 |
27 |
35 |
– |
20 |
35 |
34 |
65-74 |
22 |
25 |
29 |
24 |
– |
34 |
30 |
31 |
Social grade |
|
|
|
|
|
|
|
|
AB |
27 |
23 |
35 |
44 |
– |
35 |
41 |
47 |
C1 |
21 |
27 |
26 |
25 |
– |
32 |
29 |
28 |
C2 |
18 |
17 |
15 |
20 |
– |
15 |
20 |
28 |
DE |
13 |
17 |
14 |
18 |
– |
13 |
25 |
20 |
DEPCAT |
||||||||
1-2 |
27 |
27 |
30 |
28 |
– |
28 |
40 |
41 |
3-5 |
17 |
20 |
20 |
25 |
– |
26 |
27 |
27 |
6-7 |
15 |
18 |
16 |
18 |
– |
12 |
19 |
20 |
Base: all respondents |
1810 |
1795 |
1794 |
880 |
– |
1757 |
1742 |
1720 |
|
Significant changes (p<0.05) |
There is a clear gradient by DEPCAT with those in the more deprived areas least likely to eat five portions or more a day. It is difficult to discern any clear pattern of change over time although there does appear to have been an increase over time for those in the most affluent areas. This is illustrated in Figure 6.3.
Fig 6.3: Percentage eating at least five portions daily‚ by DEPCAT
Base: all respondents
There was a relatively consistent age gradient for fruit and vegetable consumption (Table 6.2)‚ with the percentage consuming the recommended daily amount increasing with age. As for daily fruit consumption‚ there has been a significant increase over time in the percentage eating five portions of fruit and vegetables daily for most age groups‚ with the probable exception of those aged 16-24. The increase is less marked for those aged 55-64 but people in this age group were amongst those most likely to achieve the recommended limits almost every year.
While consideration of the proportion of people consuming the recommended amount is useful in terms of measuring progress toward the current dietary targets‚ this does not provide much information on the behaviour of those who are not consuming the recommended amount. The mean number of portions eaten is approximately three per day (Table 6.3). Average consumption is higher for women than men. There is a clear social grade gradient‚ with consumption being highest for AB respondents. There is a similar gradient by DEPCAT. Consumption of fruit and vegetables also increases with age. There appear to be increasing trends across time‚ with the exception of those aged 16-24. However‚ the increase is small and average consumption is still well short of the target.
Table 6.3: Mean number of portions of fruit and vegetables consumed per day‚ by sex/age/social grade/DEPCAT
% |
1996 |
1997 |
1998 |
1999 |
2000 |
2001 |
2002 |
2003 |
All |
2.8 |
3.0 |
2.9 |
3.1 |
– |
3.1 |
3.3 |
3.4 |
Sex |
|
|
|
|
|
|
|
|
Men |
2.5 |
2.7 |
2.5 |
2.8 |
– |
2.7 |
2.8 |
2.9 |
Women |
3.1 |
3.3 |
3.3 |
3.3 |
– |
3.4 |
3.8 |
3.8 |
Age |
|
|
|
|
|
|
|
|
16-24 |
2.6 |
2.5 |
2.4 |
2.2 |
– |
2.5 |
2.4 |
2.7 |
25-34 |
2.2 |
2.6 |
2.5 |
2.8 |
– |
3.0 |
3.3 |
3.1 |
35-44 |
2.9 |
2.9 |
3.1 |
3.3 |
– |
3.1 |
3.5 |
3.4 |
45-54 |
3.3 |
3.2 |
3.3 |
3.4 |
– |
3.4 |
3.6 |
3.7 |
55-64 |
3.3 |
3.6 |
3.1 |
3.5 |
– |
3.0 |
3.8 |
3.7 |
65-74 |
2.9 |
3.4 |
3.7 |
3.4 |
– |
3.8 |
3.5 |
3.6 |
Social grade |
|
|
|
|
|
|
|
|
AB |
3.6 |
3.5 |
3.8 |
4.4 |
– |
3.9 |
4.1 |
4.4 |
C1 |
3.2 |
3.3 |
3.2 |
3.1 |
– |
3.5 |
3.5 |
3.4 |
C2 |
2.8 |
2.5 |
2.6 |
2.7 |
– |
2.7 |
2.9 |
3.1 |
D |
2.3 |
2.7 |
2.3 |
2.6 |
– |
2.8 |
3.1 |
2.9 |
E |
2.2 |
2.4 |
2.5 |
2.7 |
– |
2.2 |
2.9 |
2.8 |
DEPCAT |
||||||||
1-2 |
3.5 |
3.5 |
3.6 |
3.5 |
– |
3.5 |
3.9 |
4.1 |
3-5 |
2.7 |
3.0 |
2.8 |
3.0 |
– |
3.3 |
3.3 |
3.3 |
6-7 |
2.5 |
2.6 |
2.5 |
2.7 |
– |
2.3 |
2.8 |
2.7 |
Base: all respondents |
1810 |
1795 |
1794 |
880 |
– |
1757 |
1742 |
1720 |
Changes over time in terms of fruit and vegetable consumption are illustrated in Figure 6.4. This shows clearly the decrease in those not eating vegetables daily‚ and the associated increase in the proportion eating five or more portions a day.
Fig 6.4: Time trends in fruit and vegetable consumption‚ 1996-2003
Base: all respondents
6.3 Knowledge
There has been a significant increase in the percentage who‚ when asked how many portions of fruit and vegetables they should eat per day‚ gave an answer of five or more (Table 6.4).
% |
1996 |
1997 |
1998 |
1999 |
2000 |
2001 |
2002 |
2003 |
All |
19 |
29 |
36 |
35 |
– |
42 |
50 |
59 |
Fruit and vegetable consumption |
|
|
|
|
|
|
|
|
Daily |
26 |
37 |
46 |
43 |
– |
52 |
58 |
68 |
Non-daily |
10 |
14 |
21 |
21 |
– |
22 |
32 |
39 |
Sex |
|
|
|
|
– |
|
|
|
Men |
13 |
18 |
23 |
25 |
– |
28 |
38 |
48 |
Women |
26 |
39 |
48 |
45 |
– |
56 |
62 |
70 |
Social grade |
|
|
|
|
|
|
|
|
AB |
33 |
35 |
48 |
58 |
– |
60 |
60 |
76 |
C1 |
24 |
39 |
43 |
42 |
– |
49 |
58 |
67 |
C2 |
15 |
20 |
34 |
27 |
– |
39 |
45 |
53 |
DE |
13 |
21 |
24 |
22 |
– |
27 |
38 |
47 |
DEPCAT |
||||||||
1-2 |
26 |
38 |
53 |
45 |
– |
52 |
62 |
76 |
3-5 |
18 |
28 |
33 |
33 |
– |
45 |
50 |
60 |
6-7 |
17 |
24 |
26 |
27 |
– |
28 |
38 |
38 |
Base: all respondents |
1810 |
1795 |
1794 |
880 |
– |
1757 |
1742 |
1720 |
|
Significant changes (p<0.05) |
Knowledge levels have risen from two in ten in 1996 to six in ten in 2003. In line with the 5-a-day message‚ the majority of respondents cited the exact amount of five portions per day (59% in 2003).
Those who do not currently consume fruit and vegetables daily are notably less likely to be aware that they should be eating at least five portions a day. However‚ even among this group‚ awareness rose significantly between 1996 and 2003. As would be expected‚ knowledge levels were lower amongst those groups who were less likely to eat fruit and vegetables daily (e.g. those in the lower social grades and those in less affluent DEPCAT areas) but the difference between men and women was greater than could be explained by their differences in consumption. It is possible that‚ at least for some men‚ the family menu is set by their (female) partner and thus they may eat fruit and vegetables daily without being aware of the recommendations. There is no consistent pattern of difference by age‚ but those aged 65-74 tended to be less likely to be aware of the recommended levels.
6.4 Motivation
There appears to be a small change‚ of borderline significance‚ towards increasing motivation to eat more healthily. Until 1999‚ around half had either tried to eat more healthily or would like to do so‚ whereas from 2001 this increased to around six in ten (Table 6.5).
Table 6.5: Motivation to eat more healthily
% |
1996 |
1997 |
1998 |
1999 |
2000 |
2001 |
2002 |
2003 |
All |
|
|
|
|
|
|
|
|
Not contemplating |
47 |
47 |
49 |
50 |
– |
42 |
42 |
40 |
Would like to |
11 |
11 |
11 |
8 |
– |
10 |
14 |
10 |
Have tried |
42 |
43 |
41 |
42 |
– |
48 |
45 |
51 |
Not eating fruit and vegetables daily |
|
|
|
|
|
|
|
|
Not contemplating |
49 |
46 |
49 |
45 |
– |
46 |
34 |
46 |
Would like to |
13 |
15 |
13 |
14 |
– |
13 |
22 |
16 |
Have tried |
38 |
39 |
37 |
42 |
– |
41 |
44 |
40 |
Base: all respondents |
1810 |
1795 |
1794 |
880 |
– |
1757 |
1742 |
1720 |
Base: all not daily |
732 |
939 |
700 |
329 |
– |
586 |
544 |
509 |
|
Significant changes (p<0.05) |
For those who did not eat fruit and vegetables daily‚ their motivation to eat more healthily stayed at much the same level until 2002 when it rose to 66%. In 2003 motivation levels fell off again and returned to former levels amongst this key target group. Further data are needed to determine any longer-term patterns.
Figure 6.5 illustrates the clear change over time in both knowledge of recommended levels of consumption‚ and in motivation to eat more healthily.
Fig 6.5: Time trends in knowledge of recommended fruit and vegetable consumption and motivation to eat more healthily (tried to or would like to)‚ 1996-2003
Base: all respondents
6.5 Breastfeeding in public
Breastfeeding is another aspect of protective dietary behaviour and an aspect of the Scottish diet where there have been significant improvements. The Infant Feeding Survey 2000 (Hamlyn et al‚ 2002) showed a rising trend in breastfeeding initiation rates in Scotland from 55% in 1995 to 63% in 2000. The proportion of babies still being breastfed at 6-8 weeks rose from 34.6% in 1999 to 36.5% in 2003 (ISD‚ 2004). Improvements in breastfeeding are evident in both deprived and affluent areas. The Scottish Health Survey records 85% of mothers from deprived areas not breastfeeding at 6-8 weeks compared to 51% from affluent areas but by 2002 the proportion of mothers not breastfeeding had fallen to 76% and 44% respectively (Scottish Executive‚ 2003).
For some years‚ health education has been focused on communicating the benefits of breastfeeding for both babies and mothers and providing practical information and support. In addition‚ health education campaigns have been directed at encouraging positive attitudes amongst the general public towards breastfeeding in public places so that mothers feel more comfortable breastfeeding their babies in a variety of settings. From 1997‚ HEPS respondents were asked to what extent they agreed with a series of statements about breastfeeding. The results are shown in Tables 6.6-6.8.
Table 6.6: Agree that women should be made to feel more comfortable breastfeeding in public, by age
% |
1996 |
1997 |
1998 |
1999 |
2000 |
2001 |
2002 |
2003 |
All |
– |
84 |
82 |
82 |
– |
88 |
88 |
88 |
Age |
|
|
|
|
|
|
|
|
16-24 |
– |
78 |
82 |
64 |
– |
91 |
85 |
90 |
25-34 |
– |
91 |
91 |
93 |
– |
92 |
90 |
91 |
35-44 |
– |
88 |
91 |
90 |
– |
94 |
92 |
92 |
45-54 |
– |
83 |
80 |
81 |
– |
90 |
91 |
88 |
55-64 |
– |
92 |
68 |
81 |
– |
86 |
84 |
84 |
65-74 |
– |
71 |
74 |
74 |
– |
65 |
79 |
81 |
Base: all respondents |
– |
1795 |
1794 |
880 |
– |
1757 |
1742 |
1720 |
|
Significant changes (p<0.05) |
Attitudes towards breastfeeding were generally very positive with almost nine in ten agreeing that women should be made to feel more comfortable breastfeeding in public (Table 6.6). There is some evidence that attitudes towards breastfeeding have become more positive over time as there was a significant increase in the percentage agreeing with this statement from 1998 to 2001. This may be due to the shift in attitudes among those aged 16-24: agreement with the statement rose from eight in ten in 1997 to nine in ten in 2003. Those aged 65-74 were generally less likely to agree with this statement than younger respondents. There were no consistent differences between men and women.
Table 6.7: Disagree that women should only breastfeed at home or in private‚ by age/social grade
% |
1996 |
1997 |
1998 |
1999 |
2000 |
2001 |
2002 |
2003 |
All |
– |
73 |
73 |
74 |
– |
78 |
82 |
81 |
Age |
|
|
|
|
|
|
|
|
16-24 |
– |
70 |
74 |
59 |
– |
79 |
81 |
81 |
25-34 |
– |
82 |
84 |
89 |
– |
89 |
85 |
87 |
35-44 |
– |
80 |
81 |
82 |
– |
87 |
87 |
88 |
45-54 |
– |
76 |
68 |
74 |
– |
79 |
85 |
85 |
55-64 |
– |
65 |
59 |
67 |
– |
72 |
75 |
71 |
65-74 |
– |
54 |
65 |
60 |
– |
46 |
68 |
64 |
Social grade |
|
|
|
|
|
|
|
|
AB |
– |
79 |
75 |
76 |
– |
85 |
87 |
90 |
C1 |
– |
76 |
75 |
85 |
– |
76 |
82 |
85 |
C2 |
– |
71 |
73 |
71 |
– |
81 |
81 |
79 |
DE |
– |
67 |
70 |
65 |
– |
73 |
77 |
72 |
Base: all respondents |
– |
1795 |
1794 |
880 |
– |
1757 |
1742 |
1720 |
|
Significant changes (p<0.05) |
There was a significant shift in attitudes regarding the statement that women should only breastfeed at home or in private. In 1997‚ three in four disagreed but this had risen to over eight in ten by 2002 and 2003 (Table 6.7). The pattern of attitudes by age was similar to that seen for the previous statement. The oldest respondents were most negative‚ and while the youngest respondents started out slightly more negative‚ by 2002 they were no more negative than those aged 25-54. There was also a gradient by social grade with those in the lower social grades more negative to breastfeeding in public. There was some evidence‚ however‚ that attitudes were changing and becoming more positive over time.
Reactions to the third statement were equally positive. Over eight in ten disagreed that they would feel embarrassed to see a woman breastfeeding (Table 6.8). The number who disagreed increased significantly from 1997 to 2003‚ with attitudes becoming more positive. There was no consistent pattern by age but men were less positive‚ being more likely than women to say they would be embarrassed. There is some evidence that men are becoming less embarrassed and more positive over time.
Table 6.8: Disagree that would be embarrassed to see a woman breastfeeding‚ by sex
% |
1996 |
1997 |
1998 |
1999 |
2000 |
2001 |
2002 |
2003 |
All |
– |
81 |
80 |
80 |
– |
87 |
85 |
86 |
Sex |
|
|
|
|
|
|
|
|
Men |
– |
75 |
77 |
76 |
– |
85 |
81 |
83 |
Women |
– |
86 |
82 |
84 |
– |
89 |
89 |
89 |
Base: all respondents |
– |
1795 |
1794 |
880 |
– |
1757 |
1742 |
1720 |
|
Significant changes (p<0.05) |
Figure 6.6 shows this positive change over time in relation to all three of these attitude measures.
Fig 6.6: Time trends in attitudes to breastfeeding‚ 1997-2003
Base all respondents
Main points
- Consumption of fruit and vegetables was higher among women‚ olderrespondents and those from higher socio-economic groups.
- There was a significant increase over time among all respondentsin terms of consuming the recommended amount of fruit andvegetables‚ with the exception of the youngest age group (aged16-24) and those living in the more deprived areas.
- There have been significant overall increases in knowledge levelsregarding the current recommendation for fruit and vegetable intake.
- Attitudes towards breastfeeding in public are changing and becomingvery positive‚ although the oldest respondents tend to be slightly lesspositive. Attitudes amongst the youngest respondents (16-24) haveshown the greatest shift over time and are now more in line with thoseof other respondents.