LOTTE HOLM

FOOD HEALTH POLICIES AND ETHICS: LAY PERSPECTIVES ON FUNCTIONAL FOODS

ABSTRACT. Functional foods are a challenge to food health policies, since they question central ideas in the way that food health policies have been developed over the last decades. Driven by market actors instead of public authorities and focusing on the role of single foods and single constituents in foods for health, they contrast traditional wisdom behind nutrition policies that emphasize the role of the diet as a whole for health. Sociological literature about food in everyday life shows that technical rationality co-exists with other food related rationalities, such as practical and economic rationalities, social and relational rationalities, and symbolic rationalities that influence citizens’ ordinary eating habits. An examination of lay views on expert knowledge about food and health show that skepticism exists with respect to the basis of and balance of expert advice. Critical points with respect to how functional foods may influence routines in the populations with relevance for public health include the fact, that they promote a way of thinking of food and health that is in conflict with well-established practical ways of ensuring a balanced diet. KEY WORDS: consumers, dietary recommendations, eating habits, food and health, food culture, food symbols, functional foods, lay perspectives, nutrition policy, social and cultural aspects

INTRODUCTION Ensuring the health of populations in the area of food involves two sets of political objectives. The first revolves around the protection of the population against illness and death caused by toxins in food, whether they are naturally occurring, added during the production and processing processes, or derive from contamination from the environment. The second is about promoting general health in the population and protecting against illnesses caused by malnutrition. Deficiency diseases caused by insufficient intake of vital nutrients were the original problematic, whereas the diseases that are in focus today are seen by biomedical expertise as caused by over-nutrition and imbalanced nutrition (James, 2001). The two sets of political objectives are both informed by biomedical expert knowledge, the first by toxicology and the second by nutrition. They call upon citizens in different ways. Food safety policies typically and traditionally take the form of public regulation of the content and composition of foods offered on the market. A system of scientifically based Journal of Agricultural and Environmental Ethics 16: 531–544, 2003. © 2003 Kluwer Academic Publishers. Printed in the Netherlands.

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laws regulating the maximum acceptable levels of additives, bacteria, and contaminations is controlled by public authorities and meant to ensure that individuals may safely eat the foods that are sold on the market. In principle, food safety is thus supposed to be a matter that individuals need not reflect upon. It is taken care of by the other actors in the food sector: food producers, retailers, and public authorities. In contrast, health-promoting policies typically take the form of measures that encourage citizens to adopt healthy eating habits. The aim of these policies is to promote health and prevent diseases such as heart disease, cancer, obesity, and diabetes. Scientifically based recommendations for daily intake of nutrients are communicated to the public in the form of dietary recommendations. For decades, actions have been taken in order to encourage people to adopt diets that are varied, low in fat, rich in fiber, vitamins, and minerals. In spite of frequent controversy about details, widespread consensus exists among biomedical experts that these recommendations will serve to promote general health in the population (Stockely, 2001). Recommendations for nutrient intake are often translated into food based guidelines for how diets should be composed. Such translations take local food cultures as well as economic interests of food market actors into account (Thomas, 1991; Duff, 1999). In their popular versions, food based guidelines typically take the form of recommendations for how foods from different food groups should be combined in order to obtain a balanced diet. The concept of food groups is a central pedagogical tool in most countries and has been so for decades. Food groups typically distinguish between fruit and vegetables, cereals, dairy products, meats, fish, eggs, and fats. In public nutrition information, they are supplemented with general information about nutritional needs and guidelines for nutrient composition of diets (Christensen, 1999). In order to help consumers make informed choices about what to eat, most countries have regulations about nutrition labeling – be it optional or mandatory. Consumers are thus able to read on the labels of food products which nutrients they contain and perhaps how this quantitatively relates to recommended daily intake of those same nutrients. In most countries, it has traditionally been forbidden to draw direct inference between the composition of foods and specific health conditions or bodily functions (Hill and Knowlton, 2000). During recent years, pressure has built up to supplement these traditional instruments of nutrition policy with the marketing of functional foods, i.e, foods that are composed in order to deliver specific health benefits.

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FUNCTIONAL FOODS There is no firm and agreed definition of functional foods (Heasman and Mellentin, 2001), but most often they are described as foods that are modified so that they deliver health benefits beyond providing typical nutrients. Modification may take the form of introducing new bioactive agents in foods, of reducing content of nutrients such as fat or sugar, or of fortifying foods with more or extra nutrients. This is in fact not new. For many years, foods have been fortified in order to secure the health of populations by supplying nutrients that are scarce in the national diet. In Denmark, e.g., flour has been enriched with calcium and margarine with vitamin A (Haraldsdóttir and Thaarup, 1989). From a purely technical point of view, modifying food for health reasons is not new. The new thing about functional foods is their social contextualization. Functional foods are usually developed on the initiative of individual food producers with the purpose of strengthening their position on the food market (Heasman and Mellentin, 2001). The foods are constructed in order to obtain a marked profile, an added value in relation to similar products on the market. Even though they may reflect public health priorities, they are not developed as part of a public health policy. Consequently they appear as new versions of single products, not of whole food groups. Not all flour is fortified, only some. In order to make consumers willing to pay more for functional foods, they need to be marketed. Consequently, functional foods are associated with claims, claims about nutrient composition and claims about the health benefit they may provide (Heasman and Mellentin, 2001). These health claims are new to nutrition policy. Health claims put on single products will invite consumers to focus on the role of single products for health. There is, therefore, widespread skepticism about health claims among nutrition experts, since they challenge the widespread and agreed understanding among those experts that there is no such thing as good foods or bad foods – only good or bad diets (Lawrence and Germov, 1999).

A CHALLENGE TO TRADITIONAL NUTRITION POLICIES Seen from this perspective, functional foods run the risk of drawing the consumers’ attention away from the diet as a whole, and instead lead them to focus on single elements in foods, often also on single outcomes. Focusing on single elements in foods implies that others are ignored. It

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may be valuable to cut down fat in foods, but what if more sugar is added instead? It is an open question whether consumers will be given balanced information. The focus on how single foods may help prevent specific illnesses may lead people to ignore the multifactorial causes of many diseases, and thus risk misleading people by engaging them in endeavors to gain health that may not be the optimal ones. FOOD AND RATIONALITY However, the idea of functional foods shares the paradigm of rational individualism with other nutrition policy measures (Duff, 1999). They rest on the idea that if food consumers are properly informed, they will apply the technical rationality of nutritional science to their daily practices in order to maximize health. Consequently, nutrition policies typically focus on individual food choices and how they can best be informed, less often on the structures that form possible choices. Structures of distribution of economic and cultural resources in the population and structures related to the availability and marketing of foods are rarely addressed in public health policies (Nettleton and Bunton, 1995). Further, the emphasis on communicating biomedical rationality implies that other food related rationalities are ignored, rationalities that are important in the real world where citizens live their daily lives and eat their food. In the lives of people, food is embedded in the complexities of everyday life. Both practical, economic, symbolic, and relational rationalities are in play (Mennel et al., 1992). Practical and economic rationality relates to facts that food represent daily work and expenditure. The handling of food and eating is dependent upon the resources available and embedded in numerous other daily routines that are fitted in with the time order people live in. In doing this people try to maintain bodily functionality and well-being by balancing bodily needs with the time structures of work and private life (Kristensen et al., 2002). Meals divide the day into segments, and the rhythm of eating is thus part of this daily order and balance (Rotenberg, 1981). Symbolic rationality relates to the fact that food serves as a marker of season, summer and winter, of everyday or festivity, and of time of the day. The composition of meals is guided by rules about formats and structures (Douglas and Nicod, 1974). Both meals and specific foods carry symbolic meanings. Thus, food is a marker of identity – national, cultural, individual (Fischler, 1988). Relational rationality relates to the fact that in daily life meals are a medium for meeting with significant others (Otnes, 1991; Wood, 1995).

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Food is central for social relations everywhere in life and especially in family life. In modern societies, where individual family members typically spend the larger parts of their days in separated worlds away from home, meals serve as important media through which the family is produced and reproduced as a social entity (DeVault, 1991).

FOOD SYMBOLS AND DIETARY RECOMMENDATIONS The anthropologist Julia Twigg once described a hierarchy of foods that she found to be dominant in the Western world (Twigg, 1984). Foods do not have equal status. Some foods are deemed more important, more powerful, more valuable. Others are weaker and unimportant. At the top of the hierarchy, are the most highly prized foods: meat, especially red meat, followed by the white and bloodless types of meat. Then follow other animal products like eggs, milk, and cheese. Below the animal products follow fruits and vegetables. At the bottom of the hierarchy cereals are found as the least valued foods. The status hierarchy of foods appears in the ordering of meals. Important meals include foods from the top of the hierarchy and not from bottom. The least important meals include foods from the bottom of the hierarchy and not from the top. The importance of meals depends on: • The social occasion – ordinary or special? • Time of day – morning or evening? • Social context – important persons present or not? (Jensen, 2003). Many foods carry more specific symbolic meanings. This is very clear in the use of meat and vegetables. Meat is associated with both muscular and spiritual strength, it symbolizes power, sexuality, and social status (Fiddes, 1991). In the meal format of Western culture, meat acts as the center of the main dish of the main meal of the day. Meat defines the dish (Gvion Rosenberg, 1990). If beef is substituted with pork, the name of the dish will change from roast beef to pork roast. Meat dominates the meal, and meat is widely acknowledged to be a masculine food. Real men are thought to need meat – a view that is shared by both men and women in interview studies (Kamminga and Cunningham, 1995). In contrast, vegetables are associated with the dull everyday life. They have to do with rationality and health (Haastrup, 2003). To be a vegetable symbolizes weakness and powerlessness (Andersson, 1980; Lupton, 1996). In the meal format of Western culture, they act as side dishes not as central ones. They do not define dishes. Carrots may substitute for peas, but the dish will still be called roast-beef. Vegetables are widely acknowledged

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to be feminine foods. Women are thought to prefer vegetables and to be able to live off of vegetable dishes without meat (Holm and Møhl, 2000; Andersson, 1980; O’Doherty Jensen and Holm, 1999). The dietary guidelines encourage people to increase their intake of food from the lower part of the food hierarchy: cereals, vegetables, and fruit. They also recommend people to decrease their intake of food from the top of the hierarchy: meat in general and red meat in particular. The goal of nutrition policies can thus be understood as an attempt to lower the status of foods and meals and to feminize people’s diet. This is one reason why healthy eating is often found to be more interesting for women than for men, and why men in cultures with strong traditional ideals of masculinity often rebel against messages from nutrition education and information (O’Doherty Jensen and Holm, 1999; Karisto et al., 1993).

THE PROPER MEAL Other concepts of food and meals than those based on public health recommendations are thus at play. In interview studies with women in Britain, the women use the term “proper meal” in order to describe meals that consists of meat, potatoes, vegetables, and sauce. There are rules proscribing the preparation of this meal. The meal must be cooked from fresh ingredients, not from semi-prepared ones. It must be served at the time husbands come home from work, and women are supposed to serve proper meals like this at least 2–3 times a week (Charles and Kerr, 1988; Murcott, 1982). In so doing, they confirm that they are proper women who spend their time during the day in a suitable manner, i. e, by fulfilling their obligations as wives and mothers (Murcott, 1983). Concepts of proper meals vary between cultures and population groups, but they all have similar symbolic meanings (DeVault, 1991). Women will describe these meals as the good meal per se also in the respect that these meals are considered healthy meals. The proper meal concept thus illustrates that lay conceptions of healthy eating differ from the conceptions of biomedical expertise.

LAY CONCEPTIONS OF FOOD AND HEALTH In recent sociological analyses, the way individuals understand healthy eating has been investigated. In a project including qualitative interview studies from four European cities (Copenhagen, Frankfurt, London, and Stockholm), in-depth interviewing about the practicalities of eating

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showed that questions of food and health were part of everyday considerations about food and eating. The relation between food and health was conceptualized in a complex manner including a series of distinct themes (Holm et al., 2003). First, individuals who were parents of teenage children referred to the need to eat a varied diet. In discussions about this, they drew on those same concepts of food groups that were discussed earlier as a core part of nutrition information messages. Reference to these food groups was made routinely and these concepts appeared to be part of the everyday understanding of what eating properly is about. Individuals would use the concepts as practical tools for monitoring, evaluating, and planning their diets. Second, healthy eating was conceptualized in terms of a need to avoid substances in foods such as additives, contaminants, pesticides, hormone residuals, and bacteria. This theme belongs to the world of food safety. Contrary to the concepts drawn from nutrition information, food safety issues were discussed in very abstract terms: “E-numbers” or “E’s”, would be the term adopted to describe food additives.1 Contrary to the knowledge drawn from nutrition, the practical implications of these concepts were difficult for people to establish. Third, healthy eating was conceptualized as eating “pure” foods, i.e., foods that are homemade from raw ingredients and contain few or no additives. The eating of “pure” foods was seen as a protection against known and unknown dangers perceived to be associated with modern foods. In this and other studies (Holm and Kildevang, 1996), many individuals’ reflections about food are pervaded by the idea that modern industrial production and processing methods carry unwanted consequences with them that existing safety systems cannot predict. Consequently, skepticism prevails, which meets new technologies, such as GMO, radiation, or microwave technologies, with suspicion. Fourth, for healthy eating it was considered important to maintain a regular eating pattern and to eat healthily in a “healthy” way. This was typically described as not being a fanatic, i.e., someone who prioritizes nutrition for eating with pleasure and joy.

1 On food labels, most food additives are identified via an E-number, such as E-100.

The ‘E’ in front of the number states, that the use of the specific additive is regulated by the EU.

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NUTRITION AND FOOD SAFETY IN CONTRAST The concepts of food groups derived from public nutrition information were partially integrated in the way people talked about proper eating. Most of the food groups relate to well-known foods that people are already relating to. “I give her cornflakes, because it’s a good way of getting some dairy products into her,” “I see to it that they get a lot of vegetables,” “She is really good at eating fruits,” are all quotes from interviews that illustrate that food group concepts have practical meaning (Holm et al., 2003). These concepts are thus examples of how knowledge that derives from nutrition science is installed as everyday concepts of proper eating. In some ways, these concepts comply with cultural ideas of meal formats and they do appear to influence the composition of diets. However, as discussed earlier, studies have shown that many messages from nutrition information do not comply with cultural norms and symbolic meanings of food and meals. Many people find it hard to combine nutritional recommendations with their idea of good food. In sociological studies (Holm, 1995), many women saw this as a personal failure, leading to self reproach and guilt. Others turned their whole eating into a health project, acting in a way that others labeled fanatic – i.e., in a way that is generally seen as unhealthy. Others again refused to think about health at all (Holm, 1997). However, most people seemed to integrate at least partially nutrition recommendations in their eating habits in that they sought to vary their food intake and to include all food groups in their diet. In this sense, the concept of food groups seems to have practical implications for everyday eating. Contrary to this, concepts of food safety were talked about in a very abstract manner, and people saw them as referring to substances and elements that were invisible and, for the most part, unknown to them. Several studies have shown that no obvious link between these concepts and everyday eating seems to be established (Halkier, 2001). As a consequence, those individuals who speculated about food safety matters will typically describe their own practice in an ambivalent way. On the one hand, they do see it as their personal responsibility to ensure the safety of their diets. On the other hand, they wonder what they can they do. “You never know what they poured into it,” is a typical saying illustrating this lack of insight. Consequently, what is described in interview studies are individualized, homemade strategies, such as focusing on single foods – either by avoiding them (“never ‘concentration-camp’ eggs”) or preferring them (“always organic, when it’s not too expensive”) – or on single elements (“I look at the color. If it is too bright, something is bound to be wrong” or “I count the E-numbers. If there are more than 5, it’s a

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bad product”). Even though some consumers do not take any interest in food safety matters, they generally seem to generate a lot of confusion and anxiety (Holm and Kildevang, 1996; Halkier, 2001). The two basic elements in lay conceptions of food and health thus differ profoundly in the way they interact with people’s food practices and which problems they raise. Whereas nutrition is about foods people know of, food safety concepts are about largely unknown risks. Whereas nutritional recommendations may contrast other conceptions of good eating, food safety raises deep confusion and uncertainty about what is right and wrong. EXPERT KNOWLEDGE AND LAY OPINIONS When handling both nutrition and food safety themes people depend on the advice and knowledge stemming from biomedical experts. This type of knowledge is by some lay people met with criticism and skepticism. Examples of this appeared in an interview study about perceptions of food quality, health, and risk. Here, Danish consumers criticized expert knowledge on three points (Holm and Kildevang, ND). Expert advice was seen as unstable and undergoing frequent change. “Last year potatoes were considered fattening, now they are not,” was a typical way of expressing this criticism. The reasons why messages change is not only seen in the fact that scientific knowledge develops, but also to be found in the structural conditions under which expert knowledge is produced. Experts are seen as dependent upon attracting research funds and thus on attracting attention to their own research findings, even if these findings are of minor importance for public health. Consequently, many see experts as having double agendas. Second, biomedical knowledge is thought to have a narrow focus. Lay individuals claim that experts deal with single elements, one at a time and only more rarely in combination. It may be, people speculate, that the single additive is not dangerous, but what happens when it is combined with all the other additives or with smoking 20 cigarettes on a daily basis? Traditional biomedical experts are not seen to be trying to answer such questions. Third, the health conceptualization of biomedical knowledge is seen to be narrow. Typically health is seen as an absence of illness, or as bodily functionality. This conception ignores one of the core elements in the lay understanding of health, namely that being healthy is living a happy and harmonious life (Calnan, 1987; Herzlich, 1973). In the view of lay people health is not only a matter of the body, it is also a matter of the social and

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psychological life of individuals (Blaxter, 1990; Calnan, 1987; Herzlich, 1973). Fourth, expert knowledge is seen as out of touch with the practical, social, and symbolic realities people live with, often giving advice that is considered impossible to implement in everyday life. FUNCTIONAL FOOD AND HEALTHY EATING Functional foods may be welcomed as an easy way of improving the health of people’s eating habits without going through the struggle of persuading people to change the overall composition of their diets. Thus, functional foods may appear to be a shortcut to dietary change, which does not interfere with traditional cultural norms and values. But functional foods will in principle draw the attention away from food groups and towards specific food products, probably by focusing on the benefit of single nutrients or constituents. In this way, functional foods will introduce a detail oriented and fragmented way of communicating nutrition and healthy eating. There is a risk, therefore, whether people will react in a manner that is similar to the way they react towards food safety issues, which are also characterized by fragmentation. Food additives, pollutants, and other specific elements in foods are seen as too complex to fully understand. The question is thus whether they will react with confusion, uncertainty, and ambivalence? Some functional foods blur the traditional distinctions between food groups, e.g., by including vitamins in confectionary, fiber in drinks, fish oil in bread, and so on. Such foods contradict the basic understanding of what is a balanced diet, based on food groups. Since food group conceptions appear to be well integrated in lay understandings of healthy eating, there is a risk that such functional foods will be counter-productive to the nutritional health of populations. It is tempting to see functional foods as an efficient technological fix. However, among nutrition and health experts, the so-called “American paradox” is discussed (Heini and Weinsier, 1997; Astrup, 1998). The term refers to the phenomenon that the American food market is flooded with fat- and sugar-reduced light products at the same time as obesity in the population is highest in the world. This paradox raises the question of how people’s diets are in fact influenced by functional foods. The marketing of functional foods links individual food products to specific health benefits and to the prevention of specific diseases. It may also link food products to specific risk groups in the population. This will further tendencies to individualize eating. When foods become elements in

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a biomedically-designed diet, the role of the meal as a social mediator may change. If foods are targeted to post-menopausal women, to individuals with dispositions for heart disease or diabetes, to teenagers or older people, what will happen to the shared meal? Social scientific research about functional foods has been going on from a marketing perspective. There have been studies about what people think of functional foods and who the likely buyers of functional foods are (Bech-Larsen and Grunert, 2003; De Jong et al., 2003). There is, however, more to functional foods than buying behavior. There is a need to know more about how the inclusion of functional foods affects people’s daily practices, both on an individual and on a population basis. FUNCTIONAL FOODS AND ACTORS IN THE FOOD SECTOR Functional foods appear to create a promising market for food manufacturers (Heasman and Mellentin, 2001). They are thus important for public authorities that want to promote national or local industry, to create jobs and income. This concern needs to be balanced by concerns for public health. It is going to be very important to direct public funding for research in the health of dietary practices taken as a whole, since privately funded food research is likely to concentrate on single foods or single bioactive components in foods. Public authorities will also need to strengthen their effort to inform populations about overall dietary balance, in order to compensate for the large amount of single-food directed health information, which the food industry is likely to promote. Also, functional foods are a promising field for biomedical experts and food scientists. Functional foods and health claims are likely to draw a large complex of research, development, and regulatory research and investigation. The rise of a medical-food-industrial complex is a likely outcome of all this (Lawrence and Germov, 1999). If nutrition research is going to be directed towards the development of functional foods, it will be difficult to find independent experts. Researchers in public universities will need to counterbalance the research directed towards the development of functional foods. Finally, both food producers and retailers will have an important role to play in trying to balance the marketing of functional foods with efforts to promote healthy diets. Public authorities need to regulate how health claims on specific products should comply and perhaps be combined with overall dietary information. They also need to build alliances with the food retailers in order to promote ordinary healthy foods such as fruit and vegetables.

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As for consumers, it still remains open how they will react to functional foods. Will they see functional foods as a quick and easy way to protect their health? Will they see them as impure foods, as unnatural or perhaps risky foods? This will all depend on which kinds of foods are developed, how they are marketed, and which kind of critical debate they will raise. This again is a challenge for independent science and for critical consumers. REFERENCES Andersson, S., Matens Roller – sociologisk gastronomi (Roles of Food – Sociological Gastronomy) (Almqvist and Wicksell Förlag AB, Stockholm, 1980). Astrup, A., “The American paradox: The Role of Energy-Dense Fat-Reduced Food in the Increasing Prevalence of Obesity,” Current Opinion in Clinical Nutrition and Metabolic Care 1 (1998), 573–577. Bech-Larsen, T. and K. G. Grunert, “The Perceived Healthiness of Functional Foods – A Conjoint Study of Danish, Finnish and American Consumers’ perception of Functional Foods,” Appetite 40(1) (2003), 9–14. Blaxter, M., Health and Lifestyles (Routledge, London, 1990). Calnan, M., Health and Illness. The Lay Perspective (Tavistock Publications, London/New York, 1987). Charles, N. and M. Kerr, Women, Food and Families (Manchester University Press, Manchester/New York, 1988). Christensen, G., “Næring og nydelse i ernæringsoplysningen [Nutrition and the Pleasures of Eating in Public Information Campaigns],” Tidsskriftet Antropologi (39) (1999), 95– 107. De Jong, N., M. C. Ocke, H. A. C. Branderhorst, and R. Friele, “Demographic and Lifestyle Characteristics of Functional Food Consumers and Dietary Supplement Users,” British Journal of Nutrition 89(2) (2003), 273–281. DeVault, M. L., Feeding the Family. The Social Organization of Caring as Gendered Work (University of Chicago Press, Chicago, 1991). Douglas, M. and M. Nicod, “Taking the Biscuit: The Structure of British Meals,” New Society 19 (1974), 744–747. Duff, J., “Setting the Menu: Dietary Guidelines, Corporate Interests, and Nutrition Policy,” in J. Germov and L. Williams (eds.), The Social Appetite. A Sociology of Food and Nutrition (Oxford University Press, Victoria, 1999), pp. 77–94. Fiddes, N., Meat. A Natural Symbol (Routledge, London, 1991). Fischler, C., “Food, Self and Identity,” Social Science Information 27(2) (1988), 275– 292. Gvion Rosenberg, L., “Why Do Vegetarian Restaurants Serve Hamburgers?: Toward an Understanding of a Cuisine,” Semiotica 80(1/2) (1990), 61–79. Haastrup, L., “De ‘rigtige’ grøntsager [The ‘Correct’ Vegetables],” in L. Holm (ed.), Mad, mennesker og måltider (Munksgaard Danmark, København, 2003), pp. 113–124. Heasman, M. and J. Mellentin, The Functional Foods Revolution. Healthy People, Healthy Profits? (Earthscan Publications Ltd, Sterling, 2001). Halkier, B., “Consuming Ambivalences. Consumer Handling of Environmentally Related Risks in Food,” Journal of Consumer Culture 1(2) (2001), 205–224.

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Centre for Bioethics and Risk Assessment Department of Human Nutrition Royal Veterinary and Agricultural University Copenhagen Denmark E-mail: [email protected]