Compliance with dietary goals in a Queensland community Kathy L. Radimer Depadment of Social and Preventive Medicine, University of Queensland, Brisbane

Philip W.J. Harvey Nutrition Program, University of Queensland, Brisbane

Adele Green Quemland Institute of Medical Research, Brisbane

Elizabeth Orrell Queensland Institute of Medicul Research, Brisbane

Abstract: Dietary goals designed to improve nutritional health and lower the risk of chronic disease have been drawn up in Australia. Compliance with quantified goals was assessed in a random sample of 91 residents of Nambour, a typical community in southeast Queensland. Compliance was highest for alcohol and cholesterol goals. About three-quarters of the sample complied with the goal of limiting alcohol intake to five per cent of energy intake, and over half complied with the goal to limit daily cholesterol intake to less than 300mg. Compliance was lower for total fat and fibre goals. About 40% of the sample complied with the goal of consuming less than 33%of energy as fat or the goal of consuming 30g or more fibre per day. Compliance was slightly better for women than for men. Only a small proportion of the sample complied with goals to increase total carbohydrate intake to 55% or more of energy, or to limit saturated fatty acid intake to 10% of energy. For each of the goals, some were far from complying. In general, compliance with goals was lowest for males under 40 and was also low for women under 40. (Aust J Public Health 1992; 16: 277-81) n recent years the emphasis in the field of nutrition has changed from concern about problems associated with under-nutrition to those associated with over-nutrition. The Nutrition Task Force of the Better Health Commission (BHC), recognising the importance of diet, has set targets for dietary changes taking into account current dietary intake.' Similarly, the Commonwealth Department of Health set forth the Diets? Guidelinesfor Australians designed to 'improve the nutritional health of the population" and the National Health and Medical Research Council (NHMRC) has developed dietary

I

nutritional health of the Nambour subjects. Quantified goals from the United States have been used where none exist for Australia.

Methods In August 1990, an age-stratified random sample of 130 men and women was selected from the original study population of 2 095 participating in the Nambour Skin Cancer Prevention SurveyZ and those selected were invited to participate in a trial of skin cancer prevention. Adequate dietary data were collected on 91 (70 per cent) of these 130 adults. Data on dietary intake and supplement use were Data on compliance with dietary goals is important collected by means of a self-administered semifor public health planning, but is relatively scarce. quantitative food frequency questionnaire containThe data available often are not from randomly ing 122 items regarding the intake of specific foods sampled populations, and frequently come from or food groups. Participants were instructed to tick large urban centres. This paper examines dietary the frequency with which a specified serving size was intake in a random sample of participants in the Nambour Skin Cancer Survey, described el~ewhere.~ eaten from ten frequency choices, ranging from never to 6 4- times a day. For seasonal fruits and vegNambour is an small urban centre with a population etables, participants were asked to indicate how often of about 8 5 0 0 and is a typical Queensland these foods were eaten in season. Additional inforcommunity. mation on cooking methods and specific types of oil, Since the Australian dietary guidelines are not margarine, fat, cereals and take-away foods eaten was quantified, the quantified targets and goals set by the collected and incorporated into the nutrient BHCI and NHMRC3 have been used to assess the calculations. This instrument was based on and largely identical Correspondence to Dr Kathy Radimer, Department of Social and to the questionnaire of Willett et al., for which valPreventive Medicine, The University of Queensland, Herston idity and reliability have been e~tablished.~ It was Road, Herston Qld 4006 AUSTRALIAN JOURNAL OF PUBLIC HEALTH

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adapted to ensure that the list of foods included all those contributing significantly to the Australian diet according the National Dietary Survey of Adults: 1983.6 The language was also modified for the Australian context and its face validity and acceptability were tested before implementation in Q~eensland.~ Daily nutrient intake was calculated based upon NUTTAB90 food composition data.8 Nutrients which contribute to energy were also expressed as a percentage of total energy intake. Fibre density was calculated as g/Mj. Sodium data refer only to sodium from foods. The following dietary goals were used to assess the nutritional health of the sample: that fat intake not exceed 33 per cent and alcohol not exceed 5 per cent of energy intake set by the BHC, and the more stringent goals that fat intake not exceed 30 per cent and alcohol intake not exceed 3 per cent of energy intake set by NHMRC. Goals of saturated fat (SFA)intake of 10 per cent or less and polyunsaturated fat (PUFA) intake of between 7 and 10 per cent of energy intake, cholesterol intake of less than 300mg per day, and carbohydrate intake of 55 per cent or more of energy intake set by the United States National Research Council (NRC) were used.9 (The BHC target to reduce refined sugars to 12 per cent of energy could not be assessed because the Australian nutrient database, NUTTAB, divides carbohydrates only into starch or sugars, and the latter includes natural sugars such as those from fruit.) Statistical analyses were performed using SAS.l o

Results Nutrient intake Table 1 presents data on the mean nutrient and energy intake and the per cent of energy derived from macronutrients by sex and age. Energy intake was higher in men than women, but the percentage of energy derived from nutrients was quite similar, except for alcohol, which was significantly higher in men.

Table 2 presents data on the distributions of the percentage of energy derived from macronutrients. Relative differences between the 10th and 90th percentiles were between 1.5- and 3.5-fold for all nutrients except alcohol, for which the range was much greater. Intake in relation to dietary goals Overall, about 40 per cent of men and women met the goal of consuming less than 33 per cent of their energy as fat (Table 3). Only about half as many, however, complied with the more stringent goal of consuming less than 30 per cent of energy as fat. Adherence to both goals was lowest among subjects under 40 years of age. Compliance with goals on specific fat intake was lower, with only around 10 per cent of the sample achieving the recommended ranges for SFA and PUFA intakes. Compliance with the carbohydrate goal was lowest, with few consuming the recommended level of total carbohydrates. Compliance with alcohol goals was high, with 62 per cent of men and 72 per cent of women meeting the more stringent goal of 3 per cent of energy intake as alcohol.

Discussion The data presented in this paper indicate that while the diets in this community are better than national figures cited by the BHC' for some nutrients, they are still a long way from complying with most of the dietary guidelines. The mean contribution of total fat to energy intake was 35 per cent. This exactly meets the BHC target for 1995. Sixty per cent of men and 50 per cent of women met this target, although the two sexes had the same mean intake expressed as a percentage of energy. This figure is slightly lower than that reported by which may indicate temporal trends, regional differences, or differences in the dietary instruments. A much smaller percentage of the sample achieved the more stringent goal of con-

Table 1 : M e a n nutrient intake a n d percentage of energy derived from nutrients Mole

20-39

Female

40-59

60+

years

(n=53)

20-39

40-59

60+

years (n=15)

years

Totol

SEM

years I n = 15)

In=8)

(n=38)

SEM

years ( n = 17)

(n=22)

years I n = 14)

Total

10.65 25 2.46 436

10.28 33 2.22 318

10.30 32 2.27 373

10.28 30 2.31 370

0.57 2.1 0.13 34

8.97 32 2.03 319

9.05 31 2.02 296

7.70 29 1.79 252

8.73 31 1.98 296

0.43 2.0 0.1 1 20

17.5 40.9

16.0 43.7

16.9 43.6

16.7 42.8

0.37

Carbohydrate Total fat SFAb MUFAC PUFA~

36.4 15.4 13.0 4.3

33.5 13.3 11.8 4.9

35.5 14.4 12.3 5.4

35.0 14.3 12.3 4.8

0.80 0.44 0.32 0.23

3.5

5.2

2.2

3.9

0.69

16.8 42.7 36.5 15.6 12.7 4.6 2.2

17.1 44.7 34.5 13.7 12.2 5.3 1.8

18.6 45.0 33.0 13.6 11.1 4.8 1.8

17.3 44.0 35.0 14.4 12.1 4.9 2.0

0.48. 1.2 1.1 0.61 0.45 0.25 0.51

Nutrient intake Energy (Mil Fibre lgl Sodium (gJ Cholesterol (mgl

% Energy from Protein

Alcohol

1.1

Notes: la1 SEM = standard error of the mean. lbl SFA = saturated fatty acid. lcl MUFA = monounsaturated fatty acid. Id) PUFA = polyunsoturated fatty acid.

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suming 30 per cent or less energy from fat, suggesting that reducing most people's fat intake to this level may be difficult. The variation in intakes of specific types of fat was nearly always greater than for total fat intake (Table 2), which may indicate that substitution of one type of fat for another rather than a change in total fat intake is occurring among the sample. Of special concern is the 25 per cent of the sample whose fat intake is still over 38 per cent of energy. Over half the sample achieved the goal to limit cholesterol intake to less than 300mg per day. However, because many researchers believe that coronary

heart disease, the disease most convincingly related to fat intake, is more affected by saturated or total fat intake than dietary cholesterol's, lack of compliance with fat goals may be more important than compliance with the cholesterol goal. Compliance with the goal for total carbohydrate intake was quite low, but over half the sample consumed more than 75 per cent of the recommended level (Table 2). Refinement of the Australian nutritional data base is important in order to assess compliance with recommendations about refined sugars and complex carbohydrates.

Table 2: Distribution of nutrient intake and percentage of energy derived from nutrients

10th

25th

Percentile 50th

75th

90th

Relative difference 10th-90th

13.4 13.7

14.5 15.2

16.4 17.2

18.5 18.7

20.0 20.9

1.5 1.5

31.5 35.6

38.6 40.5

43.2 43.8

48.9 47.1

51.1 53.0

1.6 1.5

F

27.9 28.2

31.6 30.4

34.3 35.6

38.4 38.4

42.8 42.5

1.5 1.5

M

10.1

10.0

11.9 11.7

14.2 14.6

16.6

F

17.2

18.2 19.0

1.8 1.9

M F

9.8 9.6

11.1 10.6

11.9 11.8

13.4 13.6

15.1 15.4

1.5 1.6

PUFA lg)

M F

3.2 2.9

3.7 3.7

4.4 4.9

5.6 5.9

7.2 7.2

2.2 2.5

Alcohol lg)

M

0

F

0

0.4 0

1.6 0.3

6.5 3.5

9.9 6.5

M

1 75

F

148

249 200

31 1 280

399 363

589 470

3.4 3.2

M F

17 16

18 23

27 28

38 37

46 48

2.7 3.0

Percentage energy from: Protein (gl

M F

Corbohydrote (9)

M

F M

Total fat lg)

SFA lg)

MUFA lg)

Nutrient intake Cholesterol

Fibre

Table 3: Percentage of the sample complying with selected dietary goals Male

Goal Tot01 fat < 30%O Total fot < 33%b SFA S PUFA 7- 10%' Carbohydrate > 55%c Fibre 2 30gc Cholesterol < 300 mgC Alcohol S 3%" Alcohol S 5%b

+

Female

20-39 years

40-59 years

60 years

Total

20-39 years

12 23 6 6 0 18 35 65 76

27 50 15 18 9 45

21 36 7 14 0 50 50 71 79

21 38 9 13 4 38 53 62 70

13 27 13 13 13 47 53 80 87

55 55 59

+

40-59 years

60 years

Total

19

25 50 12 0 0 25 50 62 87

18 41 13 10 8 49 56 72 87

50 12 12 6 62 62 69 88

Notes: (a) NHMRC3. (b) BHC' . (cl U.S. NRC8.

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Mean fibre intake was well above the national average of 17g/day reported by the BHC for 1985 and 43 per cent of the sample reached the BHC goal of 30g/ day for the year 2000.’ Honvath states that the food frequency methodology overestimates fibre intake14 but fibre intake in this sample was substantially higher than that found in other surveys using food frequency questionnaires. Thus, the relatively high level of compliance with the fibre goal would seem to be real, rather than a methodologcal artefact. Most of the sample met the more stringent goal of consuming 3 per cent or less of their kilojoules as alcohol. Compliance was better in women, as expected, but the high compliance for both sexes is an encouraging sign that nearly all the population may meet this goal by the year 2000. However, among men, 10 per cent of the sample consumed more than 10 per cent of their energy intake as alcohol. Because of the many risks associated with high alcohol intake, alcohol consumption must still be considered a problem, despite the general high level of compliance with the goals. The BHC has set daily sodium intake targets of 3.0g for 1995 and 2.3g for the year 2000. While these data do not include salt added to food, which is very difficult to quantify, for men, the mean intake of sodium from foods alone was at the 2.3g target and for women it was slightly below this. Thus, eliminating virtually all added salt would allow the BHC targets to be achieved. However, because many people do add salt in cooking and at the table, it will be important to lower the sodium content of processed foods. The data from this study are also useful for looking at dietary intake within age and sex sub-groups. Men under 40 are of most concern. Their intakes of total fat, SFA, cholesterol, and sodium were high compared to the other sub-groups, and compliance with the dietary goals was low. In addition carbohydrate and fibre intakes were low, as were intakes of nutrients that may be protective against chronic disease: vitamin C, beta-carotene, retinol and calcium (data not presented). The nutritional health of women under 40 is also of concern. Their mean intakes for fat, SFA, and cholesterol were higher and for carbohydrates lower than for other women, and fewer of this group met the goals for fat intake. However compliance w’ h the remaining goals, and intake of beta-carotene, eti 01 equivalents, and vitamin C was similar to that of the other women. Because the size of this sample was not large, these findings should be considered tentative, awaiting confirmation from other studies in similar communities. However, the sample was drawn randomly from an unselected community group aged between 20 and 75 years, which strengthens the inferences which can be drawn from it and the response rate was good compared with other dietary surveys. Given these caveats, what conclusions about the nutritional health of communities similar to Nambour can be drawn from these findings? Compliance with alcohol and cholesterol goals in both

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sexes is highest, with over half the population complying with these goals. Conipliance with the fibre goal and the fat goal of 33 per cent of energy intake is nearly as high, around 40 per cent. For all these goals, compliance is slightly better for women. Compliance with the carbohydrate goal and the fat goals relating to specific fats (SFA and PUFA) is low, with only a very small proportion of the population complying with any of these goals. It would seem, therefore, that it is in the areas of carbohydrates and specific fat consumption that promoters of public health and the food industry need to collaborate to devise strategies to assist in dietary change. Because of the differential compliance in the various age and sex groups, different strategies targeted toward different groups may be needed, most particularly focusing on men and women under 40. However, even where compliance with goals is relatively high, some members of the population are far from meeting these goals, most notably for alcohol. Thus, there is also a need for health promotion activities targeted specifically toward those people whose eating patterns diverge markedly from those recommended by the dietary goals. Worsely has reported that most people are unaware of dietary guidelines16,although many have reported attempts to change their diets.I6.” Baghurst et al have reported that nutrient profiles lack congruence with specific dietary habits.I8 Thus, while women may be more aware of some nutrition messages and undertake specific practices such as non-fat cooking methods and trimming fat, their fat intake is not lower. In Baghurst’s data, this is due to ‘extras’ (e.g. biscuits, cakes, sauces) and dairy products. Thus, the challenge to public health promoters is not just to make people aware of dietary recommendations but also of the major sources of various nutrients, with specific suggestions for change. Continuing research on major sources of nutrients and qualitative data on what people are doing or think they should do to improve their diets will be essential in this regard. Acknowledgments The authors would like to acknowledge the data management assistance of Mr Chester Goodsell, Xyris Software Pty Ltd. and Ms Margaret-Mary Althaus. The Nambour Skin Cancer Prevention Pilot Study was funded by the Queensland Health Department. References 1 . Department of Community Services and Health. Tauardr better nutrition for Australians: Report of the nutrition taskfmce of the Better Health Commission. Canberra: Australian Government Publishing Service, 1987. 2. Commonwealth Department of Health. Dietaty guidelinesfm Australians. Canberra: Australian Government Publishing Service, 1986. 3. National Health and Medical Research Council. Drnft dietav guidelines, 1991. Unpublished. Canberra: NHMRC. 4. Green A, Beardmore G, Hart V, Leslie D, et al. Skin cancer in a Queensland population. J Am Acad Dermatol 1988; 19: 1045-52. 5. Willett WC, Sampson L, Stampfer MJ, Rosner B et al. Reproducibility and validity of a semiquantitative food frequency questionnaire. Am J Epidemiol 1985; 122: 51-65.

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6. Department of Community Services and Health. National dietary suruq, ofadults: 1983 No. 2: Nutrient intakes. Canberra: Australian Government Publishing Service, 1987. 7. Aitken J. A family history of colorectal cancer, diet, and risk of colorectal adenomas: a case-control study. [PhD thesis] Brisbane: University of Queensland, 1991. 8. Department of Community Services and Health. NU7TAB90 N u t r i d Data Tablefor use in Australia. Canberra: Australian Government Publishing Service, 1990. 9. National Research Council. Diet and health: Implications for redun'ng chronic diseme. Washington, DC: National Academy Press, 1989. 10. SAS Institute, Inc. SAS/STAT User's Guide, Release 6.03 Edition. Cary, North Carolina: SAS Institute Inc, 1988. 1 1 . Baghunt K, Crawford D, Worsley A. Syrette J et al. The Victorian nutrition survey: a profile of the energy, macronutrient and sodium intakes of the population. Cummunity Health Stud 1988; 12: 42-54. 12. Department of Community Services and Health. National dietary mmey ofadults: 1983 No. 3: Nutrient intakes by capital city. Canberra: Australian Government Publishing Service, 1989.

13. Haines AB, Sanders TAB. Dietary advice for lowering plasma cholesterol. Br Med J 1989; 298: 1594-5. 14. Horwath C. Food frequency questionnaires: a review. AustJ Nut? Diet 1990; 47: 71-6. 15. Harvey P. Dietary intake in a rural Queensland community. fioceedings of the Nutrition Society of Australia 1991; 16: 223. 16. Worsley A Crawford D. Awareness and compliance with the Australian dietary guidelines: a descriptive study of Melbourne residents. Nutrition Research 1985; 5: 1291-1308. 17. Baghurst K. Facts on changing consumer attitudes and habits. In: Corporate Nutrition Policy Seminar: Summary of proceedings. Melbourne: Victorian food and Nutrition Program, 1991. 18. Baghurst K, Crawford D, Worsley A, Record S. The Victorian Nutrition Survey-cholesterol in the Victorian population. Med J Aust 1988; 149: 12-20.

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Compliance with dietary goals in a Queensland community.

Dietary goals designed to improve nutritional health and lower the risk of chronic disease have been drawn up in Australia. Compliance with quantified...
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