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European Journal of Clinical Nutrition (2000) 54, 530±539
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A comparison of dietary behaviour in Central England and a
French Mediterranean region
M Holdsworth1*, M Gerber2, C Haslam3, J Scali2, A Beardsworth4, MH Avallone2 and E Sherratt5
1
School of Biological Sciences, University of Nottingham, Nottingham, UK; 2Groupe d'EpideÂmiologie MeÂtabolique, INSERM-CRLC,
Montpellier, France; 3Department of Human Sciences, Loughborough University, Loughborough, UK; 4Department of Social Sciences,
Loughborough University, Loughborough, UK; and 5Department of Public Health and Epidemiology, The Medical School, University of
Birmingham, Birmingham, UK
Objective: The investigation involves comparison of dietary behaviour between UK and Mediterranean France
by characterizing the pattern of the current French Mediterranean diet compared with the current British diet.
Design: The ®ndings of two dietary surveys, one in the UK and one in France, are compared. An intervieweradministered questionnaire was used in both countries. Questions on food frequency were used to assess dietary
behaviour, which were regrouped in the French survey to correspond with UK groupings. Dietary indices were
constructed to describe dietary behaviour in relation to cancer recommendations for intake of fat, ®bre, meat,
fruit and vegetables.
Setting: The UK study was conducted in Leicestershire, central England and the French study was carried out in
HeÂrault, southern France.
Subjects: UK: n ˆ 418 subjects (57.9% female and 42.1% male; mean age ˆ 45.0 y); France: n ˆ 635 subjects
(50.1% female and 40.9% male; mean age ˆ 49.8 y). Age range of both samples: 20 ± 74 y.
Results: There were positive and negative trends in food consumption in each country. UK respondents reported
eating more beans and pulses (P ˆ 0.000), less cheese (P ˆ 0.000), red meat (P ˆ 0.001), and processed meats
(P ˆ 0.000) than French respondents. However, on the negative side, they ate less fruit and vegetables
(P ˆ 0.000), ®sh and poultry (P ˆ 0.000), cereals (P ˆ 0.000), and more sweets and chocolates (P ˆ 0.000),
and cakes, pastries, biscuits and puddings (P ˆ 0.000). Women had healthier diets in both countries.
Conclusions: Overall the southern French diet was healthier as French respondents scored signi®cantly better for
indices for fat, dietary ®bre, fruit and vegetables (P ˆ 0.000 in all cases). However, the French sample scored
poorer for the meat index (P ˆ 0.000).
Sponsorship: This study was supported by a grant from l'Association de la Recherche contre le Cancer (ARC)
awarded to M Holdsworth.
Descriptors: nutrition survey; dietary habits; food habits; Mediterranean France; UK
European Journal of Clinical Nutrition (2000) 54, 530±539
Introduction
An estimated 30 ± 40% of cancer cases throughout the
world are preventable by dietary means (World Cancer
Research Fund, 1997). Cancers of the stomach, colon and
rectum are mostly preventable by appropriate diets and
related factors. Mediterranean populations have lower rates
of cancer (Cummings & Bingham,1998) and coronary heart
disease (Corpet & Gerber,1997) than Northern European
countries, suggesting that incorporating a Mediterranean
style diet in the UK could reduce the incidence of these
diseases. One of the factors contributing to the increasing
*Correspondence: M Holdsworth, Division of Nutritional Biochemistry,
School of Biological Sciences, University of Nottingham, Sutton
Bonington Campus, Loughborough, Leicestershire LE12 5RD, UK.
Guarantor: M Holdsworth.
Contributors: MH re-organized both data sets for comparison and carried
out the statistical analyses for the comparative study. MH prepared the
paper, which all investigators edited. MG supervised both the comparative
study and the French study, initiating and designing the French study. CH
and AB designed the UK study protocol and supervised data collection and
analysis. MHA collected the data for the French study and JS compiled the
database. ES collected the data for the UK study and compiled the
database.
Received 24 August 1999; revised 2 February 2000; accepted
17 February 2000
burden of cancer and coronary heart disease, particularly
in the UK, is the consumption of a diet low in fruit and
vegetables and high in saturated fat.
The conclusion that most cancers and heart disease are
preventable has enormous implications for public health
policy in the UK and France. The need for effective
nutrition education strategies that acknowledge the complex in¯uences of food choice and eating behaviour has
been identi®ed on a local (Holdsworth & Spalding, 1997)
and national level (WHO, 1996). One of the dif®culties
encountered by nutrition educators in promoting a `healthier diet' is that many consumers perceive such a diet
as tasteless and unappetising (Wardle & Solomons, 1994;
Holdsworth et al, 1997). A Mediterranean-style diet may be
a more attractive and successful way of marketing healthier
eating to consumers, as it is regarded as being palatable as
well as bene®cial to health. Cost is also a major in¯uence
on dietary change (eg LennernaÈs et al, 1997; Glanz et al,
1998) and may indeed be the key obstacle to increasing
fruit and vegetable intake in the UK (Cox et al, 1996).
The `Mediterranean diet' is characterized by a large
intake of cereals, and of diverse fresh vegetables and fruit;
a low intake of red meat, a large intake of ®sh and seafood;
almost no milk or butter, but cheese and=or yoghurts;
A comparison of dietary behaviour
M Holdsworth et al
visible fat as olive oil, and a moderate amount of red wine
during meals (Corpet & Gerber, 1997). The bene®ts to
health of such a diet have been recognized since the 1960's,
with lower incidences of coronary heart disease and cancer,
and a longer life expectancy compared with the UK (James,
1995; Gerber & Corpet, 1997, 1998).
In the UK, eating patterns have changed more than in
France, incorporating `foreign cuisine' including `Mediterranean' style cooking (Mennell, 1996). The change in
eating habits appears to be less evident in France, where
national traditions appear to have persisted; even so, a more
North American type diet is becoming popular in France,
with convenience meals becoming more widespread (Askegaard, 1993). This shift away from traditional eating habits
is also evident in southern France, particularly amongst the
young (Gerber, 1999). In a European-wide survey of dietary attitudes and beliefs (Gibney, 1997), French respondents reported that time and the cost of food were less of a
barrier to healthy eating than for UK respondents. The
French were less likely than UK respondents to perceive a
need to change eating habits (Kearney et al, 1997) and were
less likely to report that they were trying to eat healthily
(LennernaÈs et al, 1997).
The investigation reported here involves comparison of
dietary behaviour between the UK and Mediterranean
France by comparing the current French Mediterranean
diet with the current British diet. Other aspects of dietary
behaviour are also contrasted, for example use of vitamin
and mineral supplements and alcohol consumption. Recommendations are made on how the positive aspects of eating
patterns can be promoted in France and the UK for the
prevention of cancer and other diet-related diseases.
Methods
UK study
The Dietary Dilemmas study was conducted in Leicestershire, UK and is a cross-sectional study investigating dietary behaviour and attitudes to diet on a range of broad
dimensions. These relate to frequency and patterns of food
consumption, dietary change, self perceptions of health and
health-related behaviour (smoking, alcohol and exercise),
attitudes towards diet and dietary issues, nutritional knowledge and awareness, dietary concerns, and food purchase
and preparation.
The sample comprised 421 individuals drawn from the
Family Health Services register of Leicestershire Health.
The sample drawn was comparable with age pro®le statistics from the General Household Survey in Britain in 1994
(Of®ce of Population Censuses and Surveys, 1996a,b).
Three individuals were excluded from the analysis as
they were aged less than 20 y, to allow comparability
with the sample in the MEDHEA study, reducing the
sample size to 418. The ®nal response rate of the study
was 35%. Subjects were interviewed in their own homes
using an interviewer-administered, structured questionnaire
(available from the ®rst author). The design of the study has
been reported before (Goode et al, 1995, 1996). This paper
reports on the data collected on food consumption.
Questions on food frequency were used to generate data
on the frequency of consumption of key food items to allow
an assessment of dietary behaviour. Foods were listed
which were the major sources of fat, dietary ®bre and
sugar using data from the National Food Survey (Ministry
of Agriculture, Fisheries and Food, 1992). Food types=
groupings were listed and respondents were asked to record
how often they ate the foods. Foods with comparable
nutrient content were grouped together and groupings
were avoided that combined foods eaten in different circumstances. These considerations have been identi®ed as
crucial (Kemm & Booth, 1992). Portion size was not
recorded, because of the decision not to measure nutrient
intake. A full list of the 12 food groupings used is
illustrated in Table 2. Questions were also included to
measure vitamin and mineral supplement intake, breakfast
cereal consumption, type of spreading fat used and alcohol
intake.
531
French study
The population under study is a sub-sample of a larger
sample randomly recruited in HeÂrault deÂpartement, southern France, for the Mediterranean Diet and Health Study
(MEDHEA) (Gerber et al, 1997, 1999). The MEDHEA
study is cross-sectional and investigates current eating
behaviour and the socio-cultural in¯uences of food in
Mediterranean countries. The study is co-ordinated from
Montpellier, and includes 967 individuals in HeÂrault, southern France. Data on food frequency servings were available
on 635 respondents, which are included in this analysis.
Strati®ed sampling from electoral lists by age group was
conducted within the age range 20 ± 74. Respondents were
interviewed in their own homes using an intervieweradministered, structured questionnaire (available from the
®rst author). The ®nal response rate was 48%. Food
frequency and portion size of 162 individual food items
were recorded. Questions were also included to measure
vitamin and mineral supplement intake, breakfast cereal
consumption, type of spreading fat used and alcohol intake
(questionnaire available from the ®rst author).
Comparison study
Regrouping food frequency responses. The investigation
involves analysis and comparison of data on dietary behaviour: the frequencies of consumption of food types are
compared, eg how often fruit and vegetables are eaten. For
the purposes of this analysis the 162 food items in the
French food frequency questionnaire (FFQ) were arranged
into groups that corresponded with those in the UK study.
For example, the UK `Bread, rice, pasta and potatoes'
group included the frequency of: white bread, wholegrain
bread, other breads, pasta, rice, wholegrain rice, wholegrain
pasta and potatoes. All the ®nal categories are described in
Table 2.
The response categories used for the FFQ in each
country were regrouped to facilitate comparison. Three of
the frequency responses used were identical, ie never, once
a day and > once a day. The remaining two categories were
regrouped as follows: < once a week (UK) ˆ 3 times a
month=twice a month=once a month (French). The frequency category of 1 ± 6 times a week used was rather
broad but was unavoidable and resulted from the original
categories used in both studies (1 ± 3 times a week=1 ± 6
times a week (UK) and once a week=2 ± 4 times a week
(French). There was no response category for 5 ± 6 times a
week in the French study.
The frequencies of individual foods in the French study
were summed to form the ®nal response categories by
®rstly converting the frequency of response into a function
of the frequency of consumption per day. The original
categories were therefore transformed as follows:
European Journal of Clinical Nutrition
A comparison of dietary behaviour
M Holdsworth et al
532
never ˆ 0; once a month ˆ 1=30 (0.03); twice a
month ˆ 2=30 (0.07); three times a month ˆ 3=30 (0.1);
once a week ˆ 1=7 (0.14); 2 ± 4 times a week ˆ 3=7 (0.43);
once a day ˆ 7=7 (1); and at every meal ˆ 163 (3).
Frequency of food items were then summed to represent
the total frequency of consumption of foods in the ®nal
response categories. Responses were grouped so that ®nal
response categories matched the original function of days,
ie group 0 ˆ 0; group 1 ˆ > 0 but 0.1; group 2 ˆ > 0.1
but < 1; group 3 ˆ 1; group 4 ˆ > 1.
The variables for vitamin and mineral supplement
intake, breakfast cereal consumption, type of spreading
fat used and alcohol intake were recorded as follows: use
of vitamin and=or mineral supplements at least once a
month; subjects who did=did not eat cereal at breakfast;
type of spreading fat with four possible responses of
`butter', `polyunsaturated margarine', `hard margarine' or
`low fat spread'; alcohol `drinkers' and `non-drinkers'; and
number of units of alcohol drunk in a typical week.
In both studies the following demographic variables
were measured: age, gender, body mass index (BMI),
marital status and employment status. Age was reclassi®ed
into three age groups of 20 ± 34 y; 35 ± 54 y and 55 ± 74 y.
BMI was assessed from self-reported weight=height and
data was classi®ed into four groups based on the Garrow
scale (Garrow, 1983).
Data analysis. Similarities and differences between
France and the UK are highlighted and compared with
dietary recommendations for the prevention of cancer
(World Cancer Research fund=American Institute for
Cancer Research Recommendations, 1997). The Mann ±
Whitney U test was used to test the tendency for respondents in one country to exceed respondents in the other
country (Bland, 1996). The chi-squared test for association=cross-tabulations was used to test the null hypothesis
that there was no relationship between two independent
variables within a country. Analyses by age and gender
were performed. When a difference in frequency of consumption was found between the countries, data were
analysed by age groups, to ensure the differences between
the two countries did not result from a difference in age
pro®le. Analysis by social class or educational level was
not possible as we were unable to form comparable de®nitions of social class or educational level.
Developing dietary indices. In addition to describing
dietary behaviour in terms of frequency of consumption,
indices were developed to facilitate a description of eating
behaviour in broader terms. The purpose of the indices was
to summarise the data more succinctly and to compare the
®ndings with dietary recommendations for the prevention
of cancer.
Indices were developed incorporating similar principles
to those used previously in three studies (Smith & Smith,
1994; Davenport et al, 1995; Dowler & Calvert, 1995).
Indices were developed for fat, dietary ®bre, fruit and
vegetables and meat. These were chosen as they relate to
current cancer recommendations. The foods contributing to
the indices were: Fat index ˆ processed meats; chicken,
turkey and ®sh; beef, lamb and pork; cheese; sweets=
chocolates; sweet biscuits, cakes, pies, puddings and
pastries; crisps, fried snacks and peanuts; Dietary ®bre
European Journal of Clinical Nutrition
index ˆ beans and pulses; fresh=stewed fruit; vegetables
(fresh= frozen) or salad; tinned fruit and vegetables; cereals
and potatoes; Fruit and vegetable index ˆ fresh=stewed
fruit; vegetables (fresh=frozen) or salad; tinned fruit and
vegetables; Meat index ˆ processed meats; chicken, turkey
and ®sh; beef, lamb and pork.
A maximum of two points were given for a response that
met the nutrition guidelines based on recommendations
in the World Cancer Research Fund Report (1997). For
example, two points were given if the response met current
guidelines, one point was given when a response indicated
a shift towards healthier eating but not reaching the guidelines, and no points were given if the response indicated
that the individual had a long way to go before meeting
current guidelines. Foods that current guidelines recommend decreasing (processed meats, cheese, sweets and
chocolate, puddings=desserts, crisps, fried snacks and peanuts and beef, pork and lamb) were all given two points if
eaten < once a week=never; 1 point if eaten 1 ± 6 times a
week and zero points if eaten once a day. For foods that
current guidelines recommend increasing (fresh=stewed
fruit, vegetables (fresh=frozen) or salad, tinned fruit and
vegetables, chicken and ®sh, and lastly cereals and potatoes), zero points were given if eaten < once a week=never,
1 point was given if eaten 1 ± 6 times a week and 2 points if
eaten once a day. The exception was for beans and pulses,
which were considered to have met the guideline if
eaten 1 ± 6 times a week (2 points allocated), whereas
zero points were given if they were eaten less frequently.
For ease of presentation and interpretation, the scales
were adjusted so that a higher score indicates eating in line
with current guidelines for cancer prevention. Indices were
investigated within socio-demographic groups. Indices
were transformed into continuous variables by scaling
them up to 100, which meant that indices could be
compared with each other.
Results
Sociodemographic pro®le
Demographic characteristics are shown in Table 1. The UK
sample comprised more women compared with the French
sample, which had equal representation. Around a ®fth of
both samples were aged less than 34 y. The French sample
comprised more subjects in the > 54 age group compared
with the UK sample, re¯ecting the ®nding that there were
almost twice as many retired respondents in the French
sample. In terms of BMI, there were more ideal weight
respondents (41.6%) in the French sample compared with
the UK sample, whereas there were more overweight=obese
respondents (41.6%) in the UK sample compared with
35.7% in the French sample. However, these differences
in BMI pro®le did not reach signi®cance (P ˆ 0.068).
Almost three-quarters of the UK sample was working
compared with just over half of French respondents.
Unemployed respondents and students=those not seeking
work were similarly represented in both surveys.
Dietary behaviour
The frequency of consumption of the food groups described
above are illustrated in Table 2.
Fruit and vegetables. The French sample ate signi®cantly
more fruit and vegetables than the UK sample (P ˆ 0.000).
A comparison of dietary behaviour
M Holdsworth et al
Table 1 Sociodemographic characteristics of the UK and French samples
Dietary dilemmas (UK) MEDHEA (France)
Age
20 ± 34 y
35 ± 54 y
55 ± 74 y
Gender
Females
Males
BMI statusa
Group 0 (underweight)
Group 1 (ideal weight)
Group 2 (overweight)
Group 3 (obese)
Employment status
Working
Unemployed
Retired
Students=not working but
not seeking work
n
%
n
%
91
217
110
21.8
51.9
26.3
124
237
274
19.5
37.3
43.1
242
176
57.9
42.1
318
317
50.1
49.9
22
221
139
34
5.3
53.1
33.4
8.2
37
371
195
32
5.8
58.4
30.7
5.0
291
18
52
46
71.5
4.4
12.8
11.0
338
25
194
78
53.2
3.9
30.6
12.3
a
Where Group 0 (underweight) ˆ BMI < 20; group 1 (ideal weight) ˆ
BMI 20 ± 25; group 2 (overweight) ˆ BMI 26 and < 30; group 3
(obese) ˆ BMI 30.
Over 90% of the French sample ate fruit more than once a
day, compared with only a ®fth of UK respondents. The
difference was even more marked for vegetables. However,
UK respondents were signi®cantly more likely to eat tinned
fruit and vegetables (P ˆ 0.000).
Sociodemographic differences. Older respondents ate
fresh vegetables=salad and fresh=stewed fruit more often
than younger respondents in both countries (Table 3).
These trends reached signi®cance when consumption was
grouped into respondents consuming them at least once a
day and those consuming less than once a day. In the UK
this reached signi®cance for fresh vegetables=salad
(w2 ˆ 7.31df ˆ 2; P ˆ 0.026) and fresh=stewed fruit
(w2 ˆ 12.56df ˆ 2; P ˆ 0.051, Table 3). Similarly in France,
this reached signi®cance for both fresh vegetables=salad
(w2 ˆ 7.98df ˆ 2; P ˆ 0.018) and fresh=stewed fruit
(w2 ˆ 19.12df ˆ 2; P ˆ 0.000). Analysis of consumption of
fresh vegetables=salad and fresh=stewed fruit by age group
illustrated that the differences between the two countries
were not due to an age effect, as French respondents in all
age groups had signi®cantly higher consumption of fresh
vegetables=salad and fresh=stewed fruit (results not
shown).
In both countries, females ate fruit and vegetables
(except tinned) more often than males. In France, this
reached
signi®cance
for
fresh
vegetables=salad
(w2 ˆ 4.64df ˆ 1; P ˆ 0.031) with 95.0% (n ˆ 302) females
compared with 90.5% (n ˆ 287) males being high consumers. In addition, 95.9% (n ˆ 305) of females compared
with 90.5% (n ˆ 287) males were high consumers (at least
once a day) of fresh=stewed fruit (w2 ˆ 7.27df ˆ 1;
P ˆ 0.007). In the UK these gender differences in consumption of fresh vegetables=salad and fresh=stewed fruit
were also signi®cant, with 71.8% (n ˆ 173) of females
compared with 52.9% (n ˆ 91) of males being moderate
consumers (1 ± 6 times=week was the highest response
modality) of fresh vegetables=salad (w2 ˆ 15.51df ˆ 1;
P ˆ 0.000). Half of females (49.3%; n ˆ 134) were high
consumers (at least once a day) of fresh=stewed fruit
compared to 40.5% (n ˆ 68) of males (w2 ˆ 15.67df ˆ 3;
P ˆ 0.001).
533
Poultry and ®sh. The French sample ate poultry and ®sh
more often than the UK sample (P ˆ 0.000), as 11.7% of
the French sample ate these foods at least once a day
compared with 1.9% of the UK sample.
Sociodemographic differences. No difference in consumption by age or gender was detected in either country.
Red meat. The French sample ate red meat more often
than the UK sample (P ˆ 0.001), with 28.0% of the French
sample and 1.9% of the UK sample eating red meat at least
once a day.
Sociodemographic differences. In both countries, men ate
red meat more often than women. In France, 18.6%
(n ˆ 59) of females compared with 28.1% (n ˆ 89) of
males reported eating red meat at least once a day
(w2 ˆ 9.24df ˆ 2; P ˆ 0.010). The difference in gender also
reached signi®cance in the UK, with 67.4% (n ˆ 163) of
females compared with 81.8% (n ˆ 144) of males eating
red meat 1 ± 6 times a week (w2 ˆ 12.10df ˆ 2; P ˆ 0.020).
Processed meats. French respondents ate processed meats
more often than their UK counterparts (P ˆ 0.000), with
67.0% eating processed meats at least once a week compared with 45.4% of the UK sample.
Sociodemographic differences. In both countries, men ate
processed meats more often than women. In France, 15.8%
(n ˆ 50) of males compared with 4.4% (n ˆ 14) of females
reported eating processed meat at least once a day
(w2 ˆ 35.14df ˆ 3; P ˆ 0.000). The difference in gender also
reached signi®cance in the UK, with 61.9% (n ˆ 109) of
males compared with 33.5% (n ˆ 81) of females eating
processed meat 1 ± 6 times a week (w2 ˆ 36.94df ˆ 2;
P ˆ 0.000). In the French sample the under 34s (15.3%;
n ˆ 19) were more likely to eat processed meats than the
older age groups (35 ± 54 y, 7.6%; n ˆ 18; > 54 y, 9.9%;
n ˆ 27); however this did not reach signi®cance.
Beans and pulses. Beans and pulses were eaten more
often in the UK sample (P ˆ 0.000), with 71.5% eating
beans and pulses at least once a week compared with 48.8%
of the French sample.
Sociodemographic differences. In France, men ate beans
and pulses more often than women, although this did not
reach signi®cance, with 51.7% (n ˆ 164) of males compared to 45.9% (n ˆ 146) of females reporting eating beans
and pulses at least once a day (w2 ˆ 2.84df ˆ 2; P ˆ 0.242).
There was no trend for gender in the UK or for age in either
country.
Cereals and potatoes. The vast majority of the French
sample (95.4%) ate bread, potatoes, pasta or rice more than
once a day compared with under half (46.9%) of the UK
European Journal of Clinical Nutrition
A comparison of dietary behaviour
M Holdsworth et al
534
Table 2 A comparison of food frequency between French and UK respondents
Dietary Dilemmas (UK)
Fresh or stewed fruit
Never ˆ 0
less than once a week ˆ 1
1 ± 6 times a week ˆ 2
Once a day ˆ 3
> Once a day ˆ 4
Salad or vegetables (fresh or frozen)
Never ˆ 0
Less than once a week ˆ 1
1 ± 6 times a week ˆ 2
Once a day ˆ 3
> Once a day ˆ 4
Tinned fruit and vegetables
Never ˆ 0
Less than once a week ˆ 1
1 ± 6 times a week ˆ 2
Once a day ˆ 3
> Once a day ˆ 4
Chicken, turkey and ®sh
Never ˆ 0
Less than once a week ˆ 1
1 ± 6 times a week ˆ 2
Once a day ˆ 3
> Once a day ˆ 4
Beef, lamb, pork
Never ˆ 0
Less than once a week ˆ 1
1 ± 6 times a week ˆ 2
Once a day ˆ 3
> Once a day ˆ 4
Processed meats
Never ˆ 0
Less than once a week ˆ 1
1 ± 6 times a week ˆ 2
Once a day ˆ 3
> Once a day ˆ 4
Beans and pulses
Never ˆ 0
Less than once a week ˆ 1
1 ± 6 times a week ˆ 2
Once a day ˆ 3
> Once a day ˆ 4
Cereals and potatoes
Never ˆ 0
Less than once a week ˆ 1
1 ± 6 times a week ˆ 2
Once a day ˆ 3
> Once a day ˆ 4
Sweet biscuits, cakes, pies, puddings or pastries
Never ˆ 0
Less than once a week ˆ 1
1 ± 6 times a week ˆ 2
Once a day ˆ 3
> Once a day ˆ 4
Sweets or chocolates
Never ˆ 0
Less than once a week ˆ 1
1 ± 6 times a week ˆ 2
Once a day ˆ 3
> Once a day ˆ 4
Crisps, fried snacks, peanuts
Never ˆ 0
Less than once a week ˆ 1
1 ± 6 times a week ˆ 2
Once a day ˆ 3
> Once a day ˆ 4
Cheese
Never ˆ 0
Less than once a week ˆ 1
1 ± 6 times a week ˆ 2
Once a day ˆ 3
> Once a day ˆ 4
European Journal of Clinical Nutrition
n
%
9
33
174
111
91
2.2
7.9
41.6
26.6
21.8
5
149
264
0
0
1.2
35.6
63.2
Ð
Ð
84
191
133
10
0
20.1
45.7
31.8
2.4
Ð
16
35
359
7
1
3.8
8.4
85.9
1.7
0.2
33
78
299
0
8
7.9
18.7
71.5
Ð
1.9
70
158
187
3
0
16.7
37.8
44.7
0.7
Ð
23
96
290
8
1
5.5
23.0
69.4
1.9
0.2
0
1
89
132
196
Ð
0.2
21.3
31.6
46.9
11
84
174
5
144
2.6
20.1
41.6
1.2
34.4
33
177
165
37
6
7.9
42.3
39.5
8.9
1.4
52
144
185
30
7
12.4
34.4
44.3
7.2
1.7
36
69
272
39
2
8.6
16.5
65.1
9.3
0.5
MEDHEA (France)
Median
2
2
1
2
2
1
2
3
2
1
2
2
n
%
9
4
30
4
588
1.4
0.6
4.7
0.6
92.6
1
2
43
0
589
0.2
0.3
6.8
0
92.8
280
182
160
8
5
44.1
28.7
25.2
1.3
0.8
1
34
526
45
29
0.2
5.4
82.8
7.1
4.6
4
18
429
32
152
0.6
2.8
67.6
5.0
23.9
78
131
383
4
39
12.3
20.6
60.3
0.6
6.1
57
268
307
0
3
9.0
42.2
48.3
Ð
0.5
0
0
27
2
606
Ð
Ð
4.3
0.3
95.4
80
144
214
33
164
12.6
22.7
33.7
5.2
25.8
363
65
81
73
53
57.2
10.2
12.8
11.5
8.3
188
103
269
50
25
29.6
16.2
42.4
7.9
3.9
20
23
284
36
272
3.1
3.6
44.7
5.7
42.8
Median
P value
(Mann ± Whitney)
4
0.000
4
0.000
1
0.000
2
0.000
2
0.001
2
0.000
1
0.000
4
0.000
2
0.000
0
0.000
2
0.111
2
0.000
A comparison of dietary behaviour
M Holdsworth et al
535
Table 3 Differences between French and UK respondents in fruit and vegetable consumption by age
Dietary Dilemmas (UK)
Salad or vegetables (fresh or frozen)
Never=less than once a week
1 ± 6 times a week
> Once a day
Fresh=stewed fruit
Never=less than once a week
1 ± 6 times a week
Once a day
> Once a day
MEDHEA (France)
< 34 y
35 ± 54 y
> 54 y
< 34 y
35 ± 54 y
> 54 y
n
%
n
%
n
%
41
46.1
48
53.9
Ð
78
36.3
137
63.7
Ð
30
27.5
79
72.5
Ð
1
0.8
19
15.3
104
83.9
1
0.4
14
5.9
222
93.7
1
0.4
10
3.6
263
96.0
n
%
n
%
n
%
n
%
13
14.6
38
42.7
23
25.8
15
16.9
15
7.0
98
46.0
55
25.8
45
21.1
5
4.7
38
35.5
33
30.8
31
29.0
4
3.2
9
7.3
1
0.8
110
88.7
5
2.1
15
6.3
1
0.4
216
91.1
4
1.5
6
2.2
2
0.7
262
95.6
sample. The difference between the two samples reached
signi®cance (P ˆ 0.000).
Sociodemographic differences. In the UK, younger
respondents ate cereals and potatoes less often than older
respondents (w2 ˆ 12.28df ˆ 4; P ˆ 0.015). Around a third of
under 34s (38.5%; n ˆ 35) ate cereals and potatoes more
than once a day compared with 43.5% (n ˆ 95) of those
aged 35 ± 54 y and 60.0% (n ˆ 66) of those aged > 54 y. In
France, there was no difference in starchy food consumption by age.
Sweet biscuits, cakes, pies, puddings or pastries. Over a
third (34.4%) of the UK sample reported eating these foods
more than once a day compared with 25.8% of those in the
French sample. The difference between the two countries
reached signi®cance (P ˆ 0.000).
Sociodemographic differences. In both countries, men ate
these foods more often than women. In France, 29.3%
(n ˆ 93) of males compared with 23.6% (n ˆ 75) of females
ate these foods daily, although this did not reach signi®cance (w2 ˆ 5.44df ˆ 3; P ˆ 0.143). However the difference
in gender reached signi®cance in the UK, with 42.0%
(n ˆ 74) of males compared with 31.0% (n ˆ 75) females
eating these foods daily (w2 ˆ 7.95df ˆ 3; P ˆ 0.047).
Sweets or chocolate. Over half (57.2%) of the French
sample did not eat sweets or chocolate compared with only
7.9% of UK respondents (P ˆ 0.000). However there were
more `high consumers' in France, with 19.8% of the sample
eating sweets or chocolate at least once a day compared
with 10.3% of UK respondents.
Sociodemographic differences. There was no trend for
age in France but in the UK the younger age group ate
more sweets and chocolate, as 16.5% (n ˆ 15) of < 35s ate
sweets and chocolate daily compared with 11.1% (n ˆ 24)
of those aged 35 ± 54 and 3.6% (n ˆ 4) of > 54 y olds
(w2 ˆ 24.19df ˆ 6; P ˆ 0.000).
Crisps, fried snacks or peanuts. These foods were eaten
less often in the French sample, with 29.6% of respondents
reporting that they never ate these foods compared to
12.4% of UK respondents (see Table 2). However, there
was a similar distribution in frequency in both French and
UK samples for consumption of crisps, fried snacks or
peanuts at least once a week. The differences did not reach
signi®cance (P ˆ 0.111).
Sociodemographic differences. In both countries men and
younger respondents ate crisps and fried snacks more often
than their counterparts. In the UK, more men (14.8%;
n ˆ 26) than women (4.5%; n ˆ 11) ate crisps=fried
snacks daily (w2 ˆ 15.46df ˆ 3; P ˆ 0.001). In France, the
trend was similar with 14.8% (n ˆ 47) of men compared
with 8.8% (n ˆ 28) of women eating crisps=fried snacks
daily, although this did not reach signi®cance at the 5%
level (w2 ˆ 6.46df ˆ 3; P ˆ 0.091).
In relation to age, < 35 y olds in the UK were almost
twice (14.3%; n ˆ 13) as likely to eat crisps every day as
those in the 35 ± 54 y age group (8.8%; n ˆ 19) and almost
three times as likely as the over 54s (4.5%; n ˆ 5)
(w2 ˆ 35.07df ˆ 6; P ˆ 0.000). Similarly in the French
sample, 16.9% (n ˆ 21) of < 35s ate crisps=fried snacks
every day compared with 9.9% (n ˆ 27) of > 54 y olds
(w2 ˆ 32.66df ˆ 6; P ˆ 0.000).
Cheese. Cheese was eaten more frequently in the French
sample, with around half (48.5%) of French respondents
eating cheese at least once a day compared to only 9.8% of
UK respondents (P ˆ 0.000).
Sociodemographic differences. In the French sample men
ate cheese more often, as 54.3% (n ˆ 172) of men compared with 42.8% (n ˆ 136) of women reported eating
cheese every day (w2 ˆ 9.51df ˆ 3; P ˆ 0.023). In the UK
there was no trend in cheese consumption with gender.
Dietary indices
Median dietary indices are compared in Table 4, indicating
that the French sample scored signi®cantly better for fat,
dietary ®bre, fruit and vegetables. Although median meat
European Journal of Clinical Nutrition
A comparison of dietary behaviour
M Holdsworth et al
536
Table 4 A comparison of median dietary indices (of percentage) between French and UK respondents
Dietary Dilemmas (UK)
Fat index
Fibre index
Fruit and vegetable index
Meat index
MEDHEA (France)
Median
Interquartile range
Median range
Interquartile range
P value (Mann ± Whitney)
57.14
60.00
33.33
50.00
50.00 ± 64.29
50.00 ± 70.00
33.33 ± 50.00
50.00 ± 66.67
64.30
70.00
66.67
50.00
57.14 ± 71.43
60.00 ± 80.00
66.67 ± 83.33
33.33 ± 66.67
0.000
0.000
0.000
0.000
A higher score indicates eating habits in line with current recommendations.
indices were the same in each country, the inter quartile
range in the French sample was larger, re¯ecting higher
French intakes of red meat and processed meats.
Use of vitamin and mineral supplements. Vitamin and
mineral supplements were used twice as often in the UK
sample (P ˆ 0.000), with 32.3% (n ˆ 135) of the UK
sample taking them at least once a month compared with
15.3% (n ˆ 97) of the French sample.
Sociodemographic differences. In both countries, women
were more likely to use vitamin and mineral supplements
than men. This was more marked in France, with 22.6%
(n ˆ 72) of women compared with 7.9% (n ˆ 25) of men
(w2 ˆ 26.71df ˆ 1; P ˆ 0.000) in France and 39.3% (n ˆ 95)
of women compared with 22.7% (n ˆ 40) of men
(w2 ˆ 12.73df ˆ 1; P ˆ 0.000) in the UK. In France, younger
respondents ( 54 y) used vitamin and mineral supplements
more than older respondents ( > 54 y), with 19.7% (n ˆ 71)
of those aged 54 y using vitamin and mineral supplements compared with 9.5% (n ˆ 26) of those aged > 54
(w2 ˆ 12.47df ˆ 1; P ˆ 0.000). In the UK sample the trend
was in the opposite direction, as older respondents (> 54 y)
were more likely to use vitamin and mineral supplements
than younger respondents ( 54 y): 37.3% (n ˆ 41) of those
aged > 54 y used supplements compared with 30.5%
(n ˆ 94) of those aged 54 y; although this did not reach
signi®cance.
Breakfast cereals. These were eaten twice as often in the
UK, with 51.2% of the UK sample eating them compared
with 24.4% of the French sample.
Sociodemographic differences In the French sample,
younger respondents (37.1%, n ˆ 46 of < 35s and 16.4%,
n ˆ 45 of > 54s) and females (28.0%, n ˆ 89 of women and
20.8%, n ˆ 66 of men) were most likely to eat breakfast
cereals, which reached signi®cance for both age
(w2 ˆ 21.15df ˆ 2; P ˆ 0.000) and gender (w2 ˆ 4.42df ˆ 2;
P ˆ 0.036). However in the UK sample, there was no
trend in consumption with age or gender.
Type of spreading fat. The French sample (59.7%;
n ˆ 379) used butter almost three times as often as the
UK sample (19.5%; n ˆ 71). UK respondents preferred
instead to use low fat spread (UK, 30.4% (n ˆ 111) of
respondents vs France, 18.5% (n ˆ 117) of respondents),
polyunsaturated margarine (UK, 36.7% of respondents vs
France, 8.8% of respondents), and hard margarine (UK,
13.4% (n ˆ 49) of respondents vs France, 0.9% (n ˆ 6) of
respondents). UK respondents (50.1%; n ˆ 183) were therefore ®ve times more likely to use margarine than French
respondents (9.7%; n ˆ 62).
Sociodemographic differences. In the UK butter was used
signi®cantly more by older respondents (Table 5), whereas
low fat spread was used less by older respondents ( > 54 y).
In France, the trend was for butter to be used more by the
younger age groups, whereas low fat spread was more
likely to be used by the older respondents, although the
latter did not reach signi®cance in the sample. In the French
sample there were no age differences for consumption of
hard margarine or polyunsaturated margarine.
In both countries women were more likely to use low fat
spread, which reached signi®cance in the UK (see Table 5).
In the UK, men used butter more than women, although this
did not reach signi®cance, but there was no gender difference for butter use in France. In both countries there was no
Table 5 Gender and age differences for spreading fat use in French and UK respondents
Gender
Low fat spread
UK
France
Butter
UK
France
European Journal of Clinical Nutrition
Age
Men
Women
w2df ˆ 1
P-value
< 34 y
35 ± 54 y
> 54 y
w2df ˆ 2
P-value
n
%
n
%
34
21.9
51
16.1
77
36.7
66
20.8
9.15
0.002
23
25.6
59
21.5
0.480
0.129
64
32.7
39
16.5
1.47
2.30
24
30.4
19
15.3
3.17
0.205
n
%
n
%
35
22.6
190
59.9
36
17.1
189
59.4
1.68
0.195
27
30.0
145
52.9
0.010
0.897
34
17.3
151
63.7
9.27
0.02
10
12.7
83
66.9
9.52
0.090
A comparison of dietary behaviour
M Holdsworth et al
gender difference for consumption of polyunsaturated margarine. In the UK, men used hard margarine more than
women, with 20.0% (n ˆ 31) of men compared with 8.6%
(n ˆ 18) of women (w2 ˆ 10.02df ˆ 1; P ˆ 0.002), this trend
was not found in the French sample.
Alcohol. A third (33.5%; n ˆ 140) of UK respondents
reported not drinking alcohol compared with a quarter
(23.8%; n ˆ 151) of the French sample. Almost threequarters (UK, 71.9%, n ˆ 200; France, 73.9%, n ˆ 355) of
drinkers in each sample reported drinking less than 14 units
a week.
Sociodemographic differences. In both countries there
were no signi®cant differences in age distribution of nondrinkers. Gender differences were marked in both countries, as signi®cantly more men than women were drinkers,
with 76.7% (n ˆ 135) of UK men and 59.1% (n ˆ 143) of
UK women (w2 ˆ 14.19df ˆ 1; P ˆ 0.000) reporting they
drank, compared with 83.6% (n ˆ 265) of French men
and 68.9% (n ˆ 219) of French women (w2 ˆ 19.00df ˆ 1;
P ˆ 0.000).
In both countries, signi®cantly (P ˆ 0.000) more men
than women exceeded alcohol recommendations of > 14
units=week for women and > 21 units=week for men. This
was more marked in the UK, where 34.1% (n ˆ 46) of UK
men compared with 26.0% (n ˆ 69) of French men drank
more than 21 units=week. The difference between women
was not so marked with 7.7% (n ˆ 11) of UK women
compared with 6.9% (n ˆ 15) of French women drinking,
more than 14 units=week.
In the UK, the younger two age groups ( 54 y) drank
larger quantities than those aged > 54 y. Of those that
drank, almost a quarter (21.5%; n ˆ 44) of 54 y olds
compared with 9.6% (n ˆ 7) of those aged over 54 drank
heavily (> 21 units=week) (w2 ˆ 7.86df ˆ 3; P ˆ 0.049). In
France, this trend was the reverse, as more older subjects
reported drinking heavily. Of those that drank, almost a
®fth (17.0%; n ˆ 67) of 34 y olds compared with 7.8%
(n ˆ 7) of those aged < 34 y drank heavily (> 21 units=week) (w2 ˆ 9.98df ˆ 3; P ˆ 0.019).
Discussion
This study has highlighted that, although there are positive
and negative features in food consumption in each country,
the diet in the French Mediterranean is healthier overall as
French respondents scored signi®cantly better for fat, dietary ®bre, fruit and vegetables. However, the French sample
scored poorer for the meat index, re¯ecting higher French
intakes of red meat and processed meats.
On the positive side, the southern French ate signi®cantly more fruit, vegetables, cereals and potatoes, poultry
and ®sh, and fewer sweets and chocolates, cakes, pastries,
biscuits and puddings. The higher consumption of fruit and
vegetables in the French sample was not a result of
differences in the age pro®les of each sample. However,
on the negative side they ate more cheese, processed meats,
red meat and butter, all of which are rich sources of
saturated fat. In addition, French respondents ate fewer
beans and pulses. They also ate less breakfast cereals, but
as data is not available on type, we are unable to say if they
ate less of the higher ®bre=lower sugar varieties. Although
the public health message to eat more breakfast cereal is
common to both countries, the emphasis is different. In the
UK, the population is encouraged to eat lower sugar=higher
®bre varieties, whereas the French population are encouraged to increase consumption of all breakfast cereals.
On the other hand, UK respondents reported eating more
beans and pulses, low fat spread, and less cheese, red meat
and processed meats. However, on the negative side, they
ate less fruit and vegetables, ®sh and poultry, cereals and
potatoes and more sweets and chocolates, cakes, pastries,
biscuits and puddings, crisps and fried snacks. This habit of
snacking on energy-dense foods could contribute to the
higher incidences of overweight and obesity seen in the UK
sample. Data from the Food and Agricultural Organization
from 10 y ago also suggested that the French diet contains
more cereals, vegetables and ®sh than the UK diet (Hill and
Caygill, 1994).
Diets containing substantial amounts of fruit and vegetables may on their own reduce the overall incidence of
cancer by over 20%. This is therefore enormous potential
for improving diet-related cancer in the UK by focusing
primarily on increasing fruit and vegetable intake. Cummings and Bingham (1998) have suggested a need for fruit
and vegetable intake in the UK to at least double if the
recommended consumption of non-starch polysaccharides
is to be achieved. Recent campaigns (Health Education
Authority, 1992; Sharp, 1997) are a start in raising public
awareness, but it has been proposed that public health
nutrition measures need to emphasize the potential for
reduced cancer risk (Cox et al, 1996), which may be
more motivating for individuals. The barriers to consuming
more fruit and vegetables need to be addressed, particularly
the cost of fruit and vegetable dishes.
One of the main limitations of this study is that the UK
food frequency data were already grouped, whereas in the
French survey the consumption of individual food items
was recorded. This introduces an error as frequency in the
French sample may be overestimated as individuals may
overestimate their consumption more when recording individual food items than a total (Nelson & Bingham, 1996).
However, the converse may also be true as the French study
(Bonifacj et al, 1997) found that the FFQ could underestimate consumption due to insuf®cient questions on some
foods.
Although there were more alcohol drinkers in the French
sample, there was a similar distribution of units drunk in
each country. For age, the trend was worrying in the UK
from a public health perspective, as younger age groups
drank more than older ones. This was the opposite in
France, with older respondents taking larger quantities of
alcohol, which re¯ects the traditional behaviour of regular
drinking of wine with meals by older men. It would have
been useful to have had data on daily alcohol consumption
to compare intakes with current daily guides (Health
Education Authority, 1996). Unfortunately, there were no
data in the UK study on type of alcohol taken, hence a
comparison of this aspect was not possible.
UK respondents used vitamin and mineral supplements
more than French respondents. They were primarily used
by women in both countries, re¯ecting the fact that women
tend to be more health conscious and possibly more
in¯uenced by media messages. Although vitamin and
mineral supplementation may be regarded as a healthy
behaviour by the public, it is recommended that individuals
choose a healthier diet rather than supplement their diets
537
European Journal of Clinical Nutrition
A comparison of dietary behaviour
M Holdsworth et al
538
arti®cially (Department of Health, 1991; Kirk et al, 1999).
Again, age trends differed in both countries, with older
respondents using supplements more in the UK, and
younger respondents more in France. The Dietary and
Nutritional survey of British adults (Gregory et al, 1990)
also reported higher use of dietary supplements among
women and older people.
Although response rates were lower than anticipated,
both samples were representative for age pro®le, BMI and
eating behaviour. The UK sample was comparable with age
pro®le statistics from the General Household Survey in
Britain in 1994 (Of®ce of Population Censuses and Surveys, 1996a). The weight pro®le of the sample was comparable with the UK average (Of®ce of Population
Censuses and Surveys, 1996b) for mean BMI for men
(UK mean ˆ 25.8 kg=m2; study mean ˆ 25.53 kg=m2).
Mean BMI for women in the UK study sample was,
however, lower than the UK average for women (UK
mean ˆ 25.5 kg=m2; study mean ˆ 24.08 kg=m2). There
was no particular regional variation in eating habits in the
area of study that made it atypical of the UK (Ministry of
Agriculture, Fisheries and Food, 1992).
In the French study the sampling technique was
designed so that a balance of three equal age groups were
represented, which resulted in a slight over-representation
of older subjects compared to the age distribution of the
population of the region. The BMI pro®le of the sample
was comparable with the national distribution of the French
population. There was no particular regional variation in
eating habits in the area of study that made it atypical of the
French southern region.
We support the recommendations made by Assmann
et al (1998) to adopt a Mediterranean style diet in northern
European countries and to encourage the preservation of
the traditional Mediterranean diet in countries that already
have this diet. This is not a new idea and was proposed as
far back as 1614 (Haber, 1997). Such a diet could address
consumer concerns about taste and palatability (eg Glanz
et al, 1998), however, any recommendations need to be
culturally acceptable, affordable and convenient. The traditional Mediterranean diet necessitates a large variety of
fresh products, some of which are expensive and time
consuming to prepare (Gerber & Corpet, 1998).
Effective strategies for health promotion need to be
developed that promote the positive aspects of eating
patterns in France and the UK. As already stated these
need to focus on increasing fruit and vegetable consumption in the UK, as well as increasing consumption of ®sh
and poultry and cereals. The increasing use of olive oil in
the UK (International Olive Oil Council, 1998) is encouraging, but needs further promotion and preferably subsidizing on a national level so that it is affordable to all socioeconomic groups. Unfortunately there were no data from
the UK study on olive oil use. The British habit of inbetween meal snacking on energy dense foods is a large
contributor to saturated fat intake. Encouraging fruit as a
snack is the ideal solution, but a realistic approach needs to
acknowledge the place of these foods in the UK diet.
Encouraging food manufacturers to use monounsaturated
fat (in the form of olive oil preferably) in place of saturated
fat in these foods would contribute to improving the fatty
acid pro®le of the average British diet.
For the French Mediterranean population it is essential
to promote the continuation of good dietary behaviour.
Increased consumption of beans and pulses should be
European Journal of Clinical Nutrition
encouraged, particularly in traditional dishes such as casseroles, soups and salads. A reduction in consumption of
saturated fat could be achieved by discouraging high
consumption of processed meats, cheese and butter.
Having investigated the differences in food consumption
between the two countries, the next logical step seems to be
to investigate the differences in attitudes to food and
cultural in¯uences on food choice between the UK and
Mediterranean France. This is essential in the development
of appealing nutrition education messages that are both
culturally sensitive and affordable.
Acknowledgements ÐThe Dietary Dilemmas study was funded from a
grant from the Leverhulme Trust. The MEDHEA study was ®nancially
supported by the ArdeÁche and HeÂrault Committees of the `Ligue contre le
cancer', the Fondation PreÂvot and the Regional Council of LanguedocRoussillion.
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