Hard To Swallow
As a student of nutrition I was quickly made aware of my teachers’ anxiety to reform the diet of ordinary people in industrialised countries. It wasn’t malnutrition they were worried about, however. Instead it was the diseases of affluence. The typical Western diet, they said, causes nutritionally-based degenerative diseases like coronary heart disease, diabetes, cancer, large bowel disease, even tooth decay.
These diseases have become more prevalent in our society as we have grown richer and eaten more. But I was suspicious: because within our society these so-called and having had years of experience trying to wealth. Quite the opposite, in fact. They are more common in the lower social classes. Clearly whatever is wrong with our diet, it is the working classes that are worst affected.
Like many of my readers, I am a child of the working class, transformed by good education opportunities into a middle-class graduate. My own choice of food seemed to me to be part of my identity. So to be told that the food I liked was wrong challenged that identity in a way I didn’t like, I could accept that I might have bad habits. What I resented was the implication that I liked what I liked because it had been thrust upon me from cradle onwards by an ignorant mother who didn’t know about the dangers of sugar and animal fat. Later I learnt that she had also given me too much to eat, too much fat, then too much cholesterol, too little polyunsaturated fat, then too little fibre.
Luckily the professional consensus about exactly which bad habits my mother had taught me was always changing. That kept me sane. It reminded me that my mother’s meals were nourishing. For she designed them with great care, having already raised my elder siblings in the twenties and thirties, and having had years of experience trying to avoid the nutritional pitfalls of poverty.
On the diet she provided I learned to have a taste for sugar and fat. But my mother knew that such things were good. Indeed, she had learnt that this was so from extensive government propaganda during the second world war. She knew that sugar and fat provided me with energy, just as she knew that nutritionists were concerned about the dangers of too much fibre. Why else would they recommend that chalk be added to brown bread to replace the calcium they believed was lost when bran was digested? Far from being ignorant she had learned her lessons well and applied them enthusiastically.
I finally realised that it was not she, the working-class consumer, who was ignorant. She was just doing what she had been told to do. It was middle-class professionals, the doctors and nutritionists - with a bit of nudging from government officials and the emergent food industry - who charted the road to dietary salvation. True, they were sometimes a little uncertain of the precise direction in which it lay. But no evangelist has ever let doubt or uncertainty cloud his message.
Nutritionists argue that there are two different sets of nutritional diseases: deficiency diseases and nutrition-related degenerative diseases. They know a lot about deficiency diseases. Indeed there are few people who have never heard of vitamin deficiencies. The degenerative diseases are another matter. Most nutritionists are convinced that diet is of some importance in some of these diseases. But how important, and which particular factors affect which diseases, is still controversial. It may not seem so, but it is. When I was a student it was the anti-cholesterol, anti-sugar lobby who hogged the spotlight. At the moment, however, another group have got the ear of the media, They are those who believe that fat is bad and fibre is good.
So what do you choose? Processed steak and kidney pie and frozen peas or fruit, eggs and salad? If you believe that fat is bad you would vote against steak and kidney pie, since meat products, being made of cheap meats, tend to contain a lot of fat. But if you are anti-cholesterol, you should avoid eggs.
However, if you are simply trying to choose food which provides enough calories and enough essential nutrients to prevent deficiency as cheaply as possible, then frozen peas and steak and kidney pie are a sensible choice. For as well as providing the necessary vitamins, they are better value for money, calorie -wise, than eggs, fresh fruit and vegetables. Even though some people believe their health is maintained by only a thin thread, the fact is that we don’t need vitamins every day, and that most ordinary, varied diets provide us with enough vitamins over a few days.
Vitamin deficiencies have, of course, been found in the rich world as well as in developing countries. But in the vast majority of such cases the problems stem simply from not having enough to eat. The malnourished are usually undernourished. That is why children with vitamin A deficiency in Victorian England were usually shorter than average: they had insufficient food in general and that prevented them from growing to their full height. From this perspective, foods like fresh green salad and oranges are a nutritional disaster. They are just bags of water, providing little but Vitamin C and a nice taste.
The links between poverty and the diseases of deficiency are so obvious that there is no need to postulate working class ignorance to explain them. But for some reason it is more convenient to blame ignorance and not poverty for malnutrition.
In 1935, John Boyd Orr published his famous survey, Food, Health and Income, showing that 50 per cent of families in Britain ate an inadequate diet. He also pointed out that dietary adequacy fell as income fell, until, when weekly expenditure on food was less than 60 cents per family member, the diet was insufficient to sustain health. But a follow-up report from the British Medical Association, with familiar sleight of hand, turned the problem on its head. If only wise choice were exercised, they declared, a perfectly nourishing diet could be constructed for as little as 41 cents. As more than half of the malnourished poor spent more than this, their problem was clearly ignorance, not poverty.
Of course the report was rapturously received by the government of the day. And its underlying assumptions about food choice are still used in assessing welfare benefit levels in Britain today. Poor people should eat food for purely nutritional reasons. If they can’t manage, then they are not so much unfortunate as stupid. Taste and enjoyment are the prerogative of the rich.
This is the same assumption that underlies nutrition education efforts in developing countries. The poor ought to learn to be frugal. Palatability and tradition are ignored in favour of what is available, cheap and nutritious. Taken to its logical conclusions the truly zealous educator should perhaps recommend local weeds instead of cabbage, pot-roast rat as a cheap source of protein and - for B vitamins and fibre - well-rotted manure.
Yes, you are right. These are not serious suggestions. Clearly, weeds, rats and manure are not food. Food is culturally defined and our diet consists of things which our society regards as proper foodstuffs, served up in a way which it considers acceptable. And these rules apply to the rich as well as the poor.
But health and nutrition educators who recognise that the problem may be one of poverty are in a difficult position. Not only do they risk devaluing their professional currency: they are also obliged to follow the example of Boyd Orr and become social reformers. For the poor are only ignorant if you forget what their life is about. It is not about watching salt or fat or sugar or fibre in order to protect against tomorrow’s diseases. It is about staying afloat today. It is now, as it has always been, about getting through.
John Rivers is Senior Lecturer in Human Nutrition at the London School of Hygiene and Tropical Medicine.