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9 Eating habits Vasant Hirani and Paola Primatesta
The White Paper Saving Lives: Our Healthier Nation states that 'diet is central to our health throughout life'.1 There is evidence to suggest that dietary modifications such as a reduction in salt intake2,3,4 and a diet rich in fruits and vegetables, with reduced saturated and total fat, can substantially lower blood pressure, the most important risk factor for cardiovascular disease (CVD).5 High fat and energy intake raises cholesterol levels: high cholesterol levels have been associated with obesity, abdominal obesity, and non-insulin dependant diabetes mellitus.6,7,8,9,10,11 It has been shown that consumption of antioxidant vitamins 12,13,14 through dietary sources such as fruits and vegetables, flavonoids15 (other dietary antioxidants), oily fish16,17 and fibre from fruits and vegetables (in particular from cereals and grains18) can protect against the development of CVD.19,20, 21, 22,23 Hence, it has been suggested that changes in the diet of the population through education and information, and adequate access to, and availability of, a wide range of healthy foods, can aid to reduce the risk of CVD.1 Eating habits are likely to vary considerably between minority ethnic groups as a result of religious and cultural influences.24 Meat eating is a conspicuous example. Among the South Asian communities in Britain, the three main religions are Hinduism, Sikhism and Islam. Hinduism prohibits the consumption of beef; and many Hindus eat no meat at all, having vegetarian diets that may or may not include fish, eggs or dairy products. Islamic customs prohibit pork and pork products, but not other forms of meat. Sikhs have few dietary prohibitions. Some are vegetarians, and of those who eat meat, a majority follow Hindu and Muslim customs and therefore do not eat beef or pork. It has been suggested that the traditional diets of Black Caribbean, Indian, Pakistani and Bangladeshi communities are closer to the recommended dietary intake of fat and fibre than those of the white population of Britain.24,25,26 It cannot of course be assumed that the diets of minority ethnic groups closely follow those traditional in their place of origin. The extent to which they do will depend on personal preference, social and religious custom, the influence of the eating habits of the general population in Britain, and the local availability of the necessary supplies for maintaining a traditional diet. It might be expected that young people would be more likely to deviate from the traditional diet, and that, over time, more non-traditional foods would be introduced, possibly with an associated increased risk of diseases such as CVD and diabetes. There have been no large-scale nutritional surveys among the different minority ethnic populations in Britain to establish the current situation. Studies on dietary habits of migrants from the Indian sub-continent in Britain (Indians, Pakistanis and Bangladeshis) have not provided an explanation for their higher mortality rates from coronary heart disease (CHD). Some studies27,28 have hypothesised that high rates of CHD among these ethnic groups may be due to the use of ghee (clarified butter) and other cooking oils. These suggestions however do not apply to all sub-groups of the South Asian community. Curries, a prominent feature of South Asian cooking, can be quite high in fat depending on the preparation and cooking procedures, which vary among the different South Asian subgroups.29 The Health Survey for England included questions based on the Dietary Instrument for Nutrition Education (DINE) questionnaire, developed by the Imperial Cancer Research Fund's General Practice Research Group to assess dietary fat and fibre intake.30,31 (see Section 9.2). The versions of DINE that were developed by the DINE team for minority ethnic groups were used in the 1999 survey. DINE consists of a weighted food frequency questionnaire of 19 groups of food which together accounted for 70% of the fat and fibre in the typical UK diet according to the National Food Survey, together with measures of the types of spread, frying and cooking fat used.32 The DINE questionnaire was adapted for use on the Health Survey for England 1999 using ethnic versions of DINE that included a diverse range of foods consumed by different ethnic groups. (See Appendix A for a copy of the questionnaire used.) Some questions on food categories, such as meat and meat products (beef burgers or sausages, bacon, meat pies and processed meat) which were separated categories in the original DINE, were combined in the Health Survey questionnaire into one question. Scores were assigned to food groups proportionally to the fat and fibre content of a standard portion size. The DINE provides a quick assessment of an individual's diet by adding the scores relevant to the frequency of consumption of the groups of foods to give total fat and a total fibre score. The scores for the combined food question were assigned by comparison with results obtained from the Oxford and Collaborators Health Check (OXCHECK) data.33 For both fat and fibre, three categories were then derived grouping the scores: low intake (less than 30), medium intake (30-40) and high intake (more than 40). A total fat score of 30 or less on the DINE is estimated to represent a fat intake of 83 grammes per day (g/day) or less, which corresponds to about 35% of the energy recommended dietary allowance (RDA) for adults in the UK.34 A score of 40 or more indicates a fat intake greater than 122 g/day, or about 40% of energy RDA. Fibre intake was assessed from sub-scores for fruit and vegetable intake, breakfast cereal, and bread. A total fibre score of 30 or less is estimated to correspond to a dietary fibre intake of 20 g/day or less, which is about the national average, and the high fibre score of 40 or more represents more than 30 g/day. The DINE instrument does have limitations for the present survey's purposes, notably in that it does not measure total energy intake, therefore the percentage of energy contributed by fat cannot be calculated. For the 1999 Health Survey, the fat scores were adjusted in order to take the energy requirements of individuals into account. In the analysis, the energy requirement, as a proxy for energy intake, was calculated in kilocalories using reference equations from the FAO/WHO/UNU Expert Consultation.35 The equations took into account factors such as age, sex, height, weight and physical activity level of the individual. Different weights were then applied to the original DINE fat scores for each informant according to whether the informant's energy requirement was greater or lower than the general population's mean energy requirement, calculated separately for men and women since men have a higher energy requirement than women. No direct comparisons of mean fat scores and prevalence of high fat scores can therefore be made between men and women. In 1998 the questionnaire was administered by the interviewer, but in 1999 the questionnaire was self-completed by informants aged 16 and over during the nurse visit. In addition, as previously stated, questions in 1999 were altered to take the dietary habits of minority ethnic groups into account. For example dishes such as curries, casseroles, Indian snacks and sweets were included in the questionnaire in 1999. In 1999 the general population did not have a nurse visit, and were thus not asked the eating habits questions. The 1999 survey therefore does not generate general population comparisons. In most other chapters where this is the case, the 1998 survey is used instead to provide general population data, but this is not possible for the present chapter because of the differences in questionnaire and data collection method. 9.3 Consumption of selected foods 9.3.1 Fruit and vegetables In recent years, there has been increasing knowledge of the health benefits of eating fruits and vegetables. Recommendations of 400g,36 or five portions37 a day, of fruit and vegetables have been incorporated into many health strategies in the UK.1,38,39 The National Diet and Nutrition Survey of Adults40 and the most recent results of the 1998 National Food Survey (NFS),41 which uses household expenditure to estimate the average intake among the general UK population, show that the overall daily intake of fruit and vegetable (excluding potatoes) was on average only three portions per day. No surveys have provided this information about specific minority ethnic groups. Fruit Men in almost all minority ethnic groups had lower fruit consumption than women. The exception was Pakistanis, where the proportion reporting consuming fruit six or more times a week was the same for men and women (24%). A much higher proportion of Chinese men (46%) and women (60%) than of other minority ethnic groups reported consuming fruit six or more times a week. The lowest proportions were found among Bangladeshi men (15%) and women (16%). In the other four minority ethnic groups, the proportion of men reporting that they consumed fruit six or more times a week ranged from 22% to 24%. Among women, proportions were 44% for Irish women, 37% for Black Caribbean women, 28% for Indian women and 24% for Pakistani women. Table 9.1, Figure 9A Vegetables As with fruit, a much higher proportion of Chinese men than of those in other minority ethnic groups reported consuming vegetables six or more times a week. More than half of Chinese men (53%) consumed vegetables six or more times a week. The lowest proportions were found among Pakistani men (7%). Among men in the other four minority ethnic groups, the proportions who reported consuming vegetables six or more times a week were higher for Bangladeshi men (30%) than for Black Caribbean men (18%), Indian men (23%) and Irish men (22%). Among Chinese women over two-thirds (69%) reported consuming vegetables
six or more times a week, a much higher proportion than for other minority
ethnic groups. The lowest proportions were found among Pakistani women
(11%). Women in the other four minority ethnic groups had proportions
ranging from 28% to 38%. 9.3.2 Foods with high fat content A diet high in fat and saturated fatty acids (SFA) is associated with raised plasma cholesterol levels and risk of heart disease. Sources of saturated fats in the diet are meat and meat products, milk and dairy products, spreads and cooking fat, biscuits, cakes and pastries. Examples of sources of other types of fats, such as polyunsaturated fats, are vegetable oils used to fry foods. The recommendation by the Committee on Medical Aspects of Food Policy (COMA)34 is that the average contribution of saturated fatty acids should be decreased to no more than about 10% and that total fat intake should be reduced to about 35% of dietary energy. A reduction in the consumption of red meat and meat products, fried foods, sweet and savoury snacks, cakes and pastries could contribute to lowering total and saturated fatty acid intakes. Red meat A higher proportion of Bangladeshi men (13%) and women (11%) than of those in other groups consumed red meat six or more times a week. The proportion was lowest among Indian men (2%) and women (less than 1%). This result is no doubt at least partly due to religious reasons. 38% of Indian men said they rarely or never ate red meat, far higher than the next largest proportion (Pakistani men 23%). The difference was even more marked for women (52% of Indian women compared with 28% for Pakistani women, the next largest). Table 9.1, Figure 9B
A higher proportion of Bangladeshi men (13%) and women (8%) reported
consuming fried foods six or more times per week than of other groups.
The proportion was lowest for Indian men, of whom 2% reported consuming
fried foods six or more times per week. A higher proportion of Indian
men (14%) than of men in other minority ethnic groups rarely or never
ate these foods. Among women, the Irish ate fried foods the least (only
1% reported eating fried foods six or more times per week) and more
frequently (23%) reported rarely or never eating these foods. Sweet and savoury snacks The proportion of Irish men (22%) who reported consuming sweet and savoury
snacks six or more times a week was higher than that of other minority
ethnic groups. The proportion of Bangladeshi men (22%) who rarely or
never ate sweet and savoury snacks was higher than that of other minority
ethnic groups. Among women, the proportion who reported consuming sweet
and savoury snacks six or more times a week was highest among Bangladeshi
women (21%), of whom, however, the proportion who rarely or never ate
sweet and savoury snacks (26%) was also higher than for other women. Cakes and pastries Cake and pastry consumption patterns did not differ greatly between minority ethnic groups. Among men, there were no significant differences between minority ethnic groups in the proportion consuming these foods six or more times a week, although the proportion who reported rarely or never eating cakes and pastries was lower among Irish men (17%) than men in other groups. Among women, the proportion who reported consuming cakes and pastries six or more times a week was significantly higher among Irish women (6%) than among Black Caribbean women (2%), Indian women (2%) and Chinese women (1%). High levels of salt (sodium chloride) in the diet are associated with high blood pressure. A small amount is necessary (it is present in all body fluids), but most salt in food is not naturally present in high concentrations, being added during the manufacture of foods or in the home. The White Paper Saving Lives: Our Healthier Nation states that 'a modest reduction of salt in the diet could greatly reduce the risk of stroke and significantly reduce the risk of coronary heart disease'. Salt may be added to food in cooking, or may be added at table. If it is added at table, this may be done either without tasting the food or after tasting it. Informants were asked which they did, and, if they tasted the food first, whether they then added salt generally, occasionally, or rarely. Those who added it without tasting, or who tasted and then generally added salt, are referred to below as 'adding salt at table'. The questions do not give any indication of quantities added, either in cooking or at table. The practice of adding salt during cooking was almost universal among South Asian and Chinese groups, with percentages from 94% for Chinese (both sexes) and 95% upwards among South Asian men and women. Black Caribbeans were less likely to add salt during cooking (men 83%, women 81%), and Irish considerably less (men 66%, women 59%). To some extent, the Irish compensated for this by adding salt at table, their proportions being higher than for other groups. Among Irish men, the proportion adding salt at table was 53%, the next highest being Pakistani (39%) and Indian men (35%), followed by Bangladeshi (29%), Black Caribbean (28%) and Chinese men (25%). Also, if Irish men and women added salt at table, more than half of those added it without tasting, whereas South Asian and Chinese groups added it after tasting (Black Caribbeans being evenly divided in this respect). There was little difference by sex in the proportion adding salt during cooking, except that Irish men were more likely (66%) than Irish women (59%) to do so. In all groups except Bangladeshis, the proportion of men adding salt at the table was higher among men than women, the difference being particularly large in the case of Irish men (53%) and women (39%). Among Bangladeshis, the proportion was 29% for men and 35% for women. Among Irish men and women, the practice of adding salt during cooking
was more common among those aged 55 and over than among younger groups.
Among men, proportions in the three age groups were, with increasing
age, 56%, 67%, 72%, and among women 55%, 53%, 74%. In other minority
ethnic groups, there was no evidence of age patterns. 9.5.1 Fat Fat scores are explained in Section 9.2 above.
A score of over 40 is referred to below as 'high'. Among men, Irish
and Bangladeshi men had the highest adjusted mean fat score (33 and
32 respectively), and the highest prevalence of adjusted high fat score,
22% and 21% respectively. Black Caribbean men and Indian men had the
lowest adjusted mean fat score (27) and Indian men had the lowest prevalence
of adjusted high fat score (11%).
Bangladeshi women had the highest adjusted mean fat score (35) and their prevalence of adjusted high fat score (27%) was higher than for women in other minority ethnic groups (around three times as high as Black Caribbean, Indian and Chinese women and twice as high as Pakistani and Irish women). Black Caribbean and Indian women had the lowest adjusted mean fat scores (25), and Indian women had the lowest prevalence of adjusted high fat scores (8%). Irish and Pakistani women had similar prevalence of adjusted high fat intake (14% and 13%, respectively). In both sexes, Black Caribbean, Indian and Chinese men and women had similar fat intake patterns. There was very little variation in the prevalence of adjusted high fat scores (12%, 11% and 12% respectively among men and 9%, 8% and 9% among women). Among South Asians, Bangladeshis had a higher fat intake than Pakistanis and Indians; the prevalence of adjusted high fat score was 21% among Bangladeshi men, double that among Indian men (11%) and higher than the 17% among Pakistani men. Bangladeshi women (27%) had more than double the fat intake of Pakistani women (13%) and over three times the fat intake of Indian women (8%). In almost all minority ethnic groups, adjusted mean fat intake was slightly higher among younger informants (16-34 years) than among those in the two older groups, 35-54 and 55 and over. Irish men were an exception (Irish men aged 55 years and over had a higher adjusted mean fat score than those in the middle and younger age groups). The prevalence of adjusted high fat score among men in most minority ethnic groups was also higher in the younger than the middle age groups. Adjusted mean fat intake declined with age among women in almost all
minority ethnic groups, except among the Irish where those aged 55 years
and over had a slightly higher adjusted mean fat score (31) than those
in the middle (28) and younger (29) age groups. For almost all minority
ethnic groups, the prevalence of adjusted high fat score was higher
in the younger than middle age groups. The exceptions were among the
Irish women where the prevalence of high fat intake in the older age
group (22%) was nearly twice that in the middle (11%) and younger (11%)
age groups. 9.5.2 Fibre There were small differences in fibre intake between men and women in all minority ethnic groups. Bangladeshis had the lowest fibre intake (mean fibre score 22 among men and 20 among women, and prevalence of low fibre scores 79% among men and 82% among women). Indian men were less likely than men in other groups to have low fibre intake. They had the highest mean fibre score (34) and the lowest proportion with a low fibre score (40%). Chinese men and women had low mean fibre scores (25) and low proportions with high fibre scores (5% and 6% respectively), even though their intake of fruits and vegetables was the highest in comparison to other minority ethnic groups. Irish and Indian women were less likely than other groups to have low fibre intake, having the highest mean fibre scores (33 and 33) and the lowest proportion with a low fibre score (41% and 42%). The proportions of other minority ethnic groups (Black Caribbean, Pakistani, Chinese and Irish) with a low fibre score ranged from 53% to 72% among men and from 62% to 73% among women. Overall, there were no clear patterns in mean fibre score by age in either sex among almost all minority ethnic groups. The exceptions were the Irish where an increase in fibre intake with age was seen in both sexes. The proportion with a low fibre score was higher among younger informants
(16-34 years) than older informants (55 years and over) in both sexes
and in almost all minority ethnic groups. The prevalence of low fibre
score decreased with age among Black Caribbean men and women, Irish
men and Indian women. Among Indian men, the proportion with a low fibre
score was higher among those aged 35-54 (45%) than among younger (38%)
and older (28%) informants.
9.6 Socio-economic
variations in fat and fibre intake Fat Adjusted mean fat score was significantly higher among Indian and Pakistani men in manual than non-manual social classes, but there was no difference in the other minority ethnic groups. There was no significant variation in adjusted mean fat score by social class for women in all minority ethnic groups. The prevalence of adjusted high fat score was significantly higher in manual than non-manual social classes among Indian and Irish men. Among women, there were no significant differences in the prevalence of adjusted high fat score between manual and non-manual social classes in any minority ethnic group. Fibre Overall, there were no large differences in observed mean fibre score by social class for men in any minority ethnic group. Among women, there were no significant differences in observed mean fibre score by social class in most minority ethnic groups. The exceptions were Pakistani women, among whom mean fibre intake was lower in manual social classes (26) than non-manual (29). Among men, the largest difference in prevalence of low fibre score between manual and non-manual social classes was among Irish men; 56% of those in non-manual social classes had low fibre consumption compared to 49% of those in manual social classes. Smaller differences were observed among Black Caribbean and Indian men. Among Chinese and Pakistani men the reverse was evident, the proportion with low fibre consumption being lower in non-manual than manual households (non-manual: Chinese 67%, Pakistani 56%, manual: 77% and 64% respectively). Among women differences by social class in the prevalence of low fibre
score were smaller than among men. 9.6.2 Equivalised household income Fat In men and women in most minority ethnic groups, there were no significant
differences in adjusted mean fat score between household income tertiles.
The exceptions were Black Caribbean, Indian and Pakistani men and Irish
women. Among these groups the adjusted mean fat score was higher in
the middle than in the highest income tertile. Fibre Overall, there were no major differences in observed mean fibre score by income
for either sex and for any minority ethnic group. The exceptions were
among Indian men where the mean fibre score was significantly higher
among those in the middle (36) than the highest income tertile (32). References and notes 1 Saving Lives: Our Healthier Nation. The Stationery Office, London, 1999. 2 INTERSALT Cooperative Research Group. INTERSALT: an international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. BMJ 1988; 297:319-328. 3 McGregor G. Salt and Cardiovascular Disease. Cardiovascular Disease Prevention V Conference, London, 2000. 4 Law MR, Frost CD, Wald NJ. Analysis of data from trials of salt reduction. BMJ 1991; 302:819-824. 5 Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, Bray GA, Vogt TM, Cutler JA, Windhauser MM, Lin PH, Karanja N. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med 1997; 336:1117-1124. 6 Golay A, Bobbioni E. The role of dietary fat in obesity. Int J Obes Relat Metab Disord 1997; 21 Suppl 3. S2-11. 7 Kuller LH. 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Prediction of coronary heart disease using risk factor categories. Circulation.1998; 97:1837Ð1847. 12 Gaziano JM. Antioxidant vitamins and cardiovascular disease. Proc Assoc Am Phys 1999; 111/1:2-9. 13 Gey KF, Moser UK, Jordan P, Stahelin HB, Eichholzer M, Ludin E, Saris WHM, Horrobin DF, Hornstra G. Increased risk of cardiovascular disease at suboptimal plasma concentrations of essential antioxidants: An epidemiological update with special attention to carotene and vitamin C. Am J Clin Nutr 1993; 57/5 Suppl. 787S-797S. 14 Kay-Tee Khaw. Antioxidants: epidemiology, biology and trials. Cardiovascular Disease Prevention V Conference, London, 2000. 15 Hertog MGL, Kromhout D, Aravanis C, Blackburn H, Buzina R, Fidanza F, et al. Flavonoid intake and long-term risk of coronary heart disease and cancer in the Seven Countries Study. Arch Intern Med 1995;155:381-386 16 Mori TA, Beilin LJ, Burke V, Morris J, Ritchie J. Interactions between Dietary Fat, Fish, and Fish Oils and Their Effects on Platelet Function in men at risk of Cardiovascular disease. Arterioscler Thromb Vasc Biol 1997; 17: 279-286. 17 Kromhout D, Bosschieter EB, Coulander C deL. The inverse relation between fish consumption and 20-year mortality from coronary heart disease. N Engl J Med 1985; 312:1205-1209. 18 Rimm EB, Ascherio A, Giovannucci E, Spieglman D, Stampfer MJ, Willett WC. Vegetable, fruit, and cereal fiber intake and risk of coronary heart disease among men. JAMA 1996; 275: 447-451. 19 Assmann G, Carmena R, Cullen P, Fruchart JC, Jossa F, Lewis B, Mancini M, and Paoletti R. Coronary Heart Disease: Reducing The Risk: A Worldwide View . Circulation 1999; 100: 1930-1938. 20 World Health Organization. Diet, nutrition and the prevention of chronic diseases. WHO Technical Report Series 797, Geneva, Switzerland, 1990;1-203. 21 Dwyer J. Dietary approaches for reducing cardiovascular disease risks. J Nutr 1995; 125/3 Suppl. 656S-665S. 22 Posner BM, Franz MN, Quatromoni PA, Gagnon DR et al. Secular trends in diet and risk factors for cardiovascular disease: the Framingham Study. J Am Diet Assoc 1995; 95:171-179. 23 Ascherio A, Rimm EB, Giovannucci EL, Spiegelman D, Stampfer M, Willett WC. Dietary fat and risk of coronary heart disease in men: cohort follow up study in the United States. BMJ 1996; 313:84-90. 24 Nutrition in Minority Ethnic groups: Asians and Afro-Caribbeans in the United Kingdom. Health Education Authority. Briefing paper, 1991. 25 Hill SE. More than Rice and Peas: Guidelines to improve food provision for black and ethnic minorities in Britain. The Food Commision, 1990. 26 Jarvis M. Different but not unhealthy. Health Service Journal 1986; p1105. 27 Jacobson MS. Cholesterol oxides in Indian ghee: possible cause of unexplained high risk of atherosclerosis in Indian immigrant populations. Lancet 1987; ii:656-658. 28 Nath BS, Murthy R. Cholesterol in Indian Ghee. Lancet 1988; ii:39. 29 A guide to Asian diets. Social Services Section. Community Relations Commission, London, 1976. 30 Roe L, Strong C, Whiteside C, Neil A, Mant D. Dietary intervention in primary care: Validity of the DINE method for assessment. Fam Pract 1994; 11:375-381. 31 Imperial Cancer Research Fund OXCHECK Study Group. Effectiveness of health checks conducted by nurses in primary care: final results of the OXCHECK study. BMJ 1995; 310:1099-1104. 32 The Ministry of Agriculture Fisheries and Food (MAFF). Household food consumption and expenditure. Annual Reports of the National Food Survey Committee. The Stationery Office, London. 33 Roe L. Personal communication. 34 Department of Health. Diet and cardiovascular disease. HMSO, London, 1984. 35 Energy and protein requirements. Report of a joint FAO/WHO/UNU Expert Consultation. Technical report series 724. WHO 1985. 36 World Health Organisation Diet Nutrition and the Prevention of Chronic Diseases. WHO Technical Report Series 797. Geneva. Switzerland, 1990; 1-203. 37 Department of Health. Nutritional aspects of cardiovascular disease. Report of the Cardiovascular Review Group of the Committee on Medical Aspects of Food Policy (COMA). The Stationery Office, London, 1994. 38 The Scottish Office. Eating for Health- A Diet Action Plan for Scotland. The Scottish Office, Edinburgh,1996. 39 Food and Nutrition Strategy Group. Eating and Health- A Food and Nutrition Strategy for Northern Ireland. The Health Promotion Agency for Ireland, Belfast, 1996. 40 Gregory J, Foster K, Tyler H, Wiseman M.The dietary and Nutritional Survey of British Adults. OPCS, now Office for National Statistics (ONS). The Stationery Office, London, 1990 41 Ministry of Agriculture, Fisheries and Food (MAFF). National Food Survey 1998. The Stationery Office, London,1999. 9.1 Eating habits, by minority ethnic group 9.2 Adds salt to food, by age within minority ethnic group 9.3 Fat and fibre intake, by minority ethnic group 9.4 Fat and fibre intake, by age within minority ethnic group 9.5 Fat and fibre intake, by social class of head of household within minority ethnic group 9.6 Fat and fibre intake, by equivalised household income tertile within minority ethnic group
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