1467-9566.ep10932547 by haytham01


    Sociology of Health < Illness Vol. 17 No. 4 1995 ISSN 0141-9889 pp.477-494

'A healthy lifestyle might be the death of you':
discourses on diet, cholesterol control and heart
disease in the press and among the lay public
Deborah LuptiHi^ and ^mon Chapman^
 ^University of Western Sydney ^University of Sydney, Australia

Abstract        In Australia and other western countries, research on the
                relationship between dietary intake and coronary heart disease
               has attracted wide news media coverage. One of the most
                recent issues to receive media attention is the role of choles-
               terol control in reducing the risk of coronary heart disease.
               News reports on cholesterol and diet have vacillated confus-
               ingly from supporting health promotional orthodoxy in
               warning individuals to monitor carefully their intake of certain
               substances such as fats, salt and cholesterol, to questioning the
               validity of such dietary control. This paper presents the
               findings of a study investigating media coverage of and the
               responses of members of the lay public to recent diet and
               cholesterol control controversies.
                  Analysis found that while the participants commonly
               articulated concem about their diet, they also expressed a high
               degree of cynicism both in the news media's coverage and
               health promotional advice on diet and cholesterol control.
               Respondents drew upon discourses relating to the pleasurable
               nature of indulging oneself in eating, but also expressed
               moralistic discourses concerning the need to 'work' at being
               healthy, thus juggling the dialectic of health as control and
               health as release. The adage that 'everything in moderation'
               was the way to live one's life, regardless of official advice
               conceming dietary regulation, was commonly expressed as a
               strategy of coping with the confusions around diet.


From infancy and childhood, most individuals are subjected to impera-
tives, first issued by their parents, as to the quantity and types of food
® Blackwell Publishers Ltd/Editoriai Board 1995. Published by Blackwell Publisher, 108 Cowley Road,
Oxford OX4 UF. UK and 238 Main Street, Cambridge, MA 02142, USA.
478 Deborah Lupton and Simon Chapman
 they should eat in the interests of good health and physical wellbeing. In
 adulthood, food habits and regimens are maintained both through inter-
 nal regulation, the practices of the self that have been normalised through
 acculturation, and through the more overt dictates of external reg;ulation,
 via the imperatives of health promotion and medical advice. In contem-
 porary western societies, food tastes and habits are highly related to
 understandings of the 'civilized self (EUas 1978); the self who under-
 stands and accepts that certain foods are more appropriate than others to
 eat. It is foods deemed 'healthy' and 'non-fattening' that are considered
 to be appropriate, 'good' and 'civilised' foods, while fatty or sugary foods
 are categorised as 'bad', evidence of self-induigence, lack of taste and
 social refinement.
   The contemporary cultural meanings around food are replete with
 paradoxes. Food occupies the dual and conflicting roles of potential
 pathogen, sotirce of disease and death, versus those of the giver of life,
nourishment and emotional comfort. Fischler (1988) has identified the
 'omnivore's paradox', which he defines as the human biolo^cal need for,
 on the one hand, variety, diversity and innovation in food; but, on the
 other, the equal need for caution because any unknown food is a poten-
tial danger. Fischler sees this 'double bind' as creating tension and anxi-
ety in humans' relationship with food. He attributes the rules, norms and
classification systems built up around food consumption and preparation
 in all human societies as constituting, in part, attempts to resolve this
paradox (1988: 278-^9). From this perspective, the dictates conceming the
appropriateness of food in relation to establishing and maintaining good
health that are articulated by health promoters and other medical and
health professionals, may be viewed as constituting a dominant belief sys-
tem which seeks to reconcile the omnivore's paradox by categorising cer-
tain foods as 'healthy' (or 'good') and others as 'unhealthy' (or 'bad'). In
so doing, however, other paradoxes emerge, including the tension
between the need to eat certain types of 'good' food for health reasons,
and the need to eat 'bad' foods for comfort and pleasure.
   The news media are important sources for the reproduction of domi-
nant discourses and practices around food and health, acting as media-
tors between medico-scientific and lay knowledges^ In recent times, there
have been a number of highly publicised food 'scares' around the con-
tents of foodstuffs, including the presence of bacteria, preservatives, pesti-
cides, hormones and other chemicals in foods as well as their salt, sugar,
fat and cholesterol levels. As Miller and Reilly (1994) in their study of
food panics in the British media argue, the media serve as forums for the
struggle of a number of interest groups to receive public attention, includ-
ing government departments, the public relations sections of industry and
medical and scientific researchers, as well as commercial advertisers. The
media therefore tend to present contradictory accounts of foods. For
example, the media have reported medical claims about the health-dam-
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                   Discourses on diet, cholesterol control and heart disease 479

aging effects of salt, fat and cholesterol, but continue to carry advertise-
ments for the very fast and convwiience foods that are rich in such sub-
stances, using the values of luxury, glamour, nostalgia, fun, eroticism and
pleasure to highlight their desirability. The news media routinely carry
state-sponsored health education advertising supporting public health
orthodoxies conceming the association between diet and cardiovascular
health. However, in the quest to attract audiences by reporting dissent
and conflict among medical and public health researchers, the news media
also frequently publicise challenges to these orthodoxies, bringing them to
the attention of members of the public.

The cholesterol controversy: Australian press coverage

 For some time now, orthodox medical and health promotional advice has
 insisted that the reduction of dietary fats and cholesterol is vital to the
 maintenance and preservation of cardiovascular health, and that the level
 of cholesterol in the bloodstream is an important indicator of an individ-
 ual's propensity to develop coronary heart disease. The accepted wisdom
 was that a high blood cholesterol level was an indicator of an increased
 risk of heart disease and that individuals with such readings should take
 steps to modify their diet or even take drugs to lower their cholesterol
 level. Over the past decade, the interest in the relationship between blood
cholesterol levels and heart health has reached such an intensity that the
 majority of adults in most westem countries are now highly aware of
cholesterol as a potentially life-threaten ing substance; 'cholesterol aware-
ness programs have reached every comer of the westem world' (Atrens
 1994: 433). However, in recent years, there have been published a grow-
ing number of research reports and commentaries in medical journals
that have questioned the validity of the link between blood cholesterol
levels and cardiovascular disease (for example, Becker 1987, Strandberg ei
al. 1991, Oliver 1992, HuUey et ai 1992, Atrens 1994). The findings of
several cohort studies have revealed unexpected relationships between low
biood cholesterol levels and an increased risk of dying from non-cardio-
vascular diseases, and between undergoing drug therapy for high blood
cholesterol and the propensity to die from non-cardiovascular diseases, as
well as a lack of association between high blood cholesterol and cardio-
vascular deaths in women (Hulley et al. 1992, Marmot 1994). These
findings have prompted some critics to argue that mass screening and
treatment of blood cholesterol is not advisable, and indeed may even be
ethically suspect, and should be limited to the minority of people deemed
to be at very 'high risk' from coronary heart disease for factors other
than their cholesterol level (HuUey et al. 1992, Oliver 1992, Davey Smith
and Egger 1994, Atrens 1994).
    It was some time before the debate around the value of cholesterol
                                         © Blackwei! Publishers Ltd/Editorial Board 1995
480 Deborah Lupton and Simon
 control played out in medical journals b ^ a n to make itself heard in the
 mainstream news media. In Australia, the issue was first given high
 prominence with the publication in the prestigious Journal of the
 American Medical Association of preliminary findings from the so-called
 'Finnish businessmen's study* (Strandberg et al 1991). The paper
 reported the outcome of a five year trial aimed at preventing coronary
 heart disease in over a thousand middle-aged men resident in Finland.
 Half the men had been randomly selected to join the intervention group.
This involved them consulting regularly with health {H'ofessionals who
 advised them about diet, physical activity and smoking, and treated them
 with drugs if hypertension or high blood cholesterol levels were evident.
 Unexpectedly, when the trial ended of the men who had adjusted their
diet and lifestyle in response to their high blood cholesterol levels and
high blood pressure readings, there were more non-fatal heart attacks and
more deaths from heart disease. Ten years later, when the subjects were
 followed up, it was found that the intervention group continued to expe-
rience a higher level of mortality from all causes.
   The findings of the 'Finnish businessmen's study' resulted in the publi-
cation of several lengthy articles in Australian newspapers discussing the
cholesterol controversy, bearing such challenging headlines as 'A
 Telegraph Mirror [Sydney], 24 December 1991) and 'CUTTING CHO-
23 December 1991). However, the majority of articles rebutted the
findings of the Finnish study, their headlines making such claims as
(Mercury [Hobart], 21 Febmary 1992) and 'EXPERTS DISMISS
FINNISH CHOLESTEROL STUDY' (West Australian, 24 December
   News and documentary television reports also debated the issue,
including a segment of the high-rating current affairs programme '60
Minutes', in August 1992, that called into question the integrity of the
Australian National Heart Foundation and posed a trenchant critique of
the cholesterol orthodoxy. Such coverage, then, laid bare a source of dis-
sent within medical and public health circles conceming the relative value
or harm of reducing blood cholesterol levels for coronary heart health.
While most news articles supported continuing cholesterol control in the
interests of preventing heart disease, the very reporting of the existence of
dissent revealed the contentious nature of the issue, bringing it to the
attention of readers who otherwise would not have been aware that there
were challenges to the orthodoxy of cholesterol control.
   Since 1991, a steady stream of Australian media reports have consid-
ered the medical debate about the value of cholesterol control in prevent-
ing coronary heart disease. To study further recent press coverage of the
relationship between heart disease and diet and the cholesterol contro-
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                   Discourses on diet, cholesterol control and heart disease 481
 versy, we analysed press clippings from all Australian national and
 regional newspapers published in the eight month period between January
 and August 1993*. The clippings were entered into a database and coded
 for their sotirce, date of publication and up to two major topics. Of the
 total of 745 news articles published during this period, 189 discussed gen-
 eral risk factors and preventive advice for heart disease, while 74 were
 concemed with the role of diet in general in contributing to or preventing
 heart disease and 70 discussed the preventive role of exercise. A further
 33 articles specifically concentrated on the link between dietary choles-
 terol and/or fat and heart disease. Comparatively few articles covered sur-
 gical or drug therapies for heart disease; 79 were about heart surgery or
 other medical interventions and 15 were about new drug treatments for
 heart disease (such as aspirin). Many of the remaining articles publicised
 the activities of the Australian National Heart Foundation (153 articles)
 or discussed the general health effects of heart disease (260 articles).
    Specific issues that received press attention during this time included a
 link found between eating margarine and heart disease in a long-running
 American study of more than 85,000 female nurses, occasioning such
 Morning Herald, 6 March 1993). The articles emphasised that previous
 medical advice conceming the health benefits of eating margarine rather
 than butter had now been overtumed by this study. A number of other
 articles asserted that foods or other lifestyle choices previously considered
 to be damaging to heart health or cholesterol levels were apparently
 beneficial, including a story on the alleged cholesterol-lowering properties
 CHOLESTEROL' {Mercury, 23 March 1993) - and articles about the
 benefits of drinking red wine and instant coffee and eating nuts, featuring
 such headlines as 'A DRINK A DAY IS GOOD FOR THE HEART'
{Australian, 11 August 1993) and 'HUMBLE NUT COULD BE HEART
SAVER' {Canberra Times, 5 March 1993).
    The controversy around cholesterol continued to be reported in 1993.
For example, an article in the Canberra Times (31 March 1993) was head-
explicitly challenged health promotional orthodoxies around dietary cho-
lesterol control. One example is an opinion piece that appeared in
Brisbane's Sunday Mail (28 March 1993) by columnist Bob Hart. The
article recounted the story of Hart attending for heart health screening
along with well-known Australian sports stars and actors. Despite Hart's
description of himself as 'an overweight pudding fancier whose 10-year-
old joggers are still in mint condition', he triumphantly reported that his
serum cholesterol level was found to be lower than that of ex-Australian
test cricketer Dennis Lillee, 'a slim, fit man who stays that way by eating
sensibly and swimming at least 2 km five times a week'. The headline of
the piece read 'LONG LIVE THE PUDDING KING'. However, the
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482 Deborah Lupton and Simon Chapman
orthodox position on the benefits of reducing salt, fatty foods and smok-
ing to enhance heart health also continued to appear in newspaper
reports. For example, an article headlined 'KILLING ME SOFTLY
WITH GOOD FOOD* (Herald Sun [Melbourne], 8 Mareh 1993), claimed
that 'Australia is digging its own grave with a knife and fork. As a nation
we are literally eating ourselves to death*.

Tbe focus group discussions

 Health promotional discourses seek to represent the causes of heart disease
 as being relatively controllable and certain. The emergence of controversy
 over a putative factor such as blood cholesterol, receiving high publicity in
 the news media, has the potential of creating anxiety and uncertainty about
 the predictive power of modem medicine and epidemiology, and challenges
 the credibility of public health advice about lifestyle. While a number of
 recent qualitative studies have examined the discourses articulated by
(mostly British) people in relation to health and diet (for example, Pill 1983,
Williams 1983, Crawford 1984, Cahian 1990, Calnan and Williams 1991,
Backett 1992, Watson 1993, Saltonstall 1993, Backett et al. 1994) and more
specifically in relation to heart disease (Davison et al. 1991, Davison et al.
 1992), few published studies have explicitly examined public awareness of
and responses to the cholesterol controversy as it has been reported in the
media, or have elicited the responses of Australians on these issues.
   To address these questions, a series of 12 semi-structured focus group dis-
cussions were carried out with people resident in Sydney between January
and May 1994. Focus group discussions are a useful means of encouraging
groups of people to explore questions in ways that allow the sharing of
opinions and experiences. Discussing issues in a group allows participants
to 'bounce ideas off each other' and disablement between members of the
groups may generate productive discussion in ways which are not available
in the semi-structured one-to-one interview. Group discussions axe also less
time-consuming than the one-to-one interview method. However, it should
be acknowledged this means of eliciting data, like any other research
method, also has its limitations. These include the relative superficiality of
the insights gained into each participant's perspKtive and experience in
group discussions compared with those that may be gained through the
interview fonnat. There is also the problem of some or all members of the
groups feeling inhibited about expressing their views in the group setting.
The focus group moderator needs to be wary of allowing some participants
to dominate others. Group discussions may also be better suited to areas of
research that do not involve highly personal or controversial issues, ^ven
the 'public* nature of participation in such groups and the possible subse-
quent reluctance of participants to express their opinions and recount their
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                       Discourses on diet, cholesterol control and heart disease 483

   Participants were elicited through snowball sampling. Table 1 provides
demographic details of the group members. Of the total of 49 people
involved in the discussions, 32 were female and 17 male; 22 participants
were aged between 19 and 39 years, and 27 were aged between 40 and 77
years. The majority of participants were in paid employment, ranging
from manual, sales and clerical work to hairdressing, nursing and man-
agement, and all were of Anglo-Celtic ethnicity. In order to facilitate par-
ticipants' responses in a relaxed environment, the groups consisted largely
of pre-established social networks - friends, relatives or workmates - and
were mostly carried out as tape-recorded 'chats' in the home of the inter-
viewer over tea or coffee.

Table i. Focus groups participants

Group 1: female nurse, 21 years; female real estate property assistant, 45; male student, 20;
female student, 20; female student, 22.
Group 2: TemaJe hostess, 54; female shop manager, 56; female, retired, 77.
Grot^ 3: male student, 25; female teacher, 22; female teacher, 22; female teacher, 22; male
sales manager, 22.
Group 4: female receptionist, 46; female homeworker, 77; self-employed female, 39; female
cashier, 50; female cashier, 41.
Group 5: female clerk, 40; male investor, 43; female community worker, 45; male software
duplicator, 30; female nurse, 23.
Group 6: female secretary, 47; female accounts clerk, 51; female community nurse, 49.
Group 7: female homeworker. 60; female homeworker, 70; female hairdresser, 55; female
homeworker, 65.
Group 8: femaie homeworker, 42; female nurse, 55; female shop assistant, 19; female hair-
dresser, 24.
Group 9: female sales assistant, 29; female shop manager, 51; female patternmaker, 23.
Group !0: male optical dispenser and fire fighter, 43; male truck driver, 2i; male labourer,
42; malefirefighter,38.
Group II: male employment officer, 28; male sales manager. 38; male teacher, 43; male
financial analyst. 23; male business adviser, 29.
Group 12: male promotions manager, 28; male customer relations worker. 49; male enter-
tainment and promotions manager. 41; male public relations manager, 49.

   The focus group discussions began with general questions on the rela-
tionship between health and lifestyle. Questions then focused more
specifically on media coverage of health and diet. Each member of the
group was given to read copies of three recent newspaper clippings on
diet, cholesterol and heart disease which gave contradictory advice about
whether diet and cholesterol control was beneficial or negative for heart
health. Participants were asked what they made of such news coverage
and how they knew what was the 'right' thing to do {ie. what sorts of
food one should be eating or not eating in the interests of health). Lastly
they were asked who they thought they could 'trust' to get the 'right'
advice about what to do to keep healthy.
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484 Deborah Lupton and Simon Chapman
   Analyses of the media/audience relationship need to con^tter the vari-
eties of audience response as well as the content of media texts.
Individuals do not simply and pas^vely ^absorb* the intended meaxiings
of m ^ a accounts but respond in a variety of ways contingent on histori-
cal and social conditions. Therefore, rather than accepting the notion of a
homogeneous audience responding in predictable ways to media texts, it
is more appropriate to think in terms of multiple 'reading positions', to
which audience members bring a number of pre-existing discourses in the
act of 'making sense' of a news text (Dahlgren 1988, Bennett and
WooUacott 1988, Moores 1990). As our interest was primarily in lan-
guage use rather than attempting to describe the 'authentic' experiences
and feelings of the participants, the transcripts of the discussions were
analysed for the discourses forming the interpretive repertoires that par-
ticipants drew on to articulate their understandings of the nexus between
health and diet and their response to the cholesterol controversy.
Interpretive repertoires are broad, recurrently used systems of terms that
are employed to characterise and evaluate phenomena and are often
arranged around specific, limited metaphors and figures of speech (Potter
and Wetherell 1987: 149). This analytic concept is useful for analysing
contested areas, for it acknowledges variability rather dian consensus or
consistency in the way that people represent phenomena, and accepts that
individuals commonly use competing or contradictory as well as cohesive
explanations in conversation, drawing upon various interpretive reper-
toires to perform different tasks and to present themselves in certain ways
(Potter and Wetherell 1987: 156). The use of interpretive repertoires is
therefore highly socially and spatially contextual.

Good health and preventive

As foimd in previous British studies (for example, Cahian 1990, Calnan
and Williams 1991, Davison et al. 1992) the majority of participants were
highly aware of the orthodoxies around the prevention of heart disease and
other illnesses, including the strictures around diet. As Davison et al.
(1992: 676) assert, individuals are by no means 'victims of their own igno-
rance'. A dominant interpretive repertoire evident in the participants'
accounts was that of good health as a conscious strategic activity.
Participants commonly olwerved that good health is what one 'does', or
what one avoids in the interests of the preservation of one's health (c/".
Crawford 1984, Watson 1993, Saltonstall 1993). Health states were also
frequently elided with the activities of everyday life: health is 'your lifestyle'
as one woman (group 4) observed. Participants comment^ that the
accomplishment and maintenance of good health involves such activities as
eating 'good* food, regular exercise and watching one's weight: for exam-
ple, one shoxild 'exercise every day and drink two litres of water every day.
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                    Discourses on diet, cholesterol control and heart disease 485

Have all your vegies and all that kind of thing' (woman, group 4).
   It was cmnmonly stated that good health was an achievement, some-
thing that had to be worked at, something you 'do' rather than possess
naturally: 'it is hard work. You have to devote yourself to it' (man,
group 3). Keeping healthy may be a matter of luck, but it is also about
constant vigilance. As such, it was difficult to establish and maintain
good health. It is a matter of discipline, for it involves giving up things
like spare time or enjoyed foods. As one man in group 3 noted, health
and fitness activities are 'not natural'; they involve a 'conscious decision
to become healthy'. It is difficult to maintain a routine, given all the
other demands of life {cf Crawford 1984: 67-8, Saltonstall 1993: U). It is
also harder when one gets older: 'I mean, anyone can be fit at 20 but in
your 40s you have to work at it' (man, group 5).
   When discussing causes of good and Ul health, a moralistic discourse
was evident in some participants' responses, referring to the notions that
'we are what we eat', that we are each personally responsible for our
state of health. For example, one woman (group 2) recounted the story of
a friend of hers who had cancer of the colon due to her 'really, reaily
bad' dietary habits and who, despite her illness, 'is still doing the wrong
things to her body'. A woman in group 8 commented that some people
are unhealthy because 'they abuse their health, they don't look after
themselves', while another in that group followed up her remark by not-
ing that others 'care more about their bodies and what they're doing to it
and what they put into it'. In illustrating this point, one woman in group
2 used the mechanical metaphor of the body to describe how health
states are produced and maintained:
  My father always used to use the example that if you had a car and
  you put bad petrol and bad oil into it, it would not go. So it is the
  same with our bodies - if we put the wrong food and we drink the
  wrong things, then our bodies are going to stop too.
   Building on the mechanical metaphor, several participants described
good health as possessing enough energy to get through the day and to
carry out one's everyday functions and responsibilities. Health was thus
represented as a resource for living {cf. Watson 1993). A further interpre-
tive repertoire represented good health as being related to a certain state of
mind, involving maintaining a level of motivation to continue to 'work' at
securing good health and having a 'positive attitude' about life. It was
noted by several participants that feeling depressed and lethargic was
strongly related to feeling physically unwell and to eating the 'wrong' foods,
and vice versa; for example, a woman (group 8) commented, 'basically if
I'm not happy I tend to eat and I'll eat the wrong thing. But if I'm feeling
good I eat the right things'. This repertoire echoes Calnan and Johnson's
(1985: 60) findings in their study of women living in London, in which the
respondents expressed the belief that one must be happy to be healthy.
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486 Deborah Lupton and Simon Cbsjanan
   A nostalgic discourse was evident in the accounts of several people,
particularly those over 40 years of age, who recalled how they ate any-
thing in their childhood, a time when there was not anxiety around what
was in the food and how 'healthy' or 'imhealthy' it was. It was com-
monly argued that whereas once people used to eat a lot of food, it was
good, hearty 'natural' food and it kept them going throughout a day of
heavy physical labour. There was a tendency to describe a 'golden' age of
'natural' living, in which people (commonly grandparents, or pai^nts for
the older participants) lived on the land, often in rural areas or on farms,
and engaged in manual labour involving heavy exercise as well as eating
solid, large meals with the family. The view put forward was that life was
simpler then: people did not suffer from stress, and did not have to worry
about the health value of their diet. Some participants argued that
although the old-style food may be considered 'unhealthy' by today's
standards, people flourished and lived to a ripe old age on such a diet:
   My mother used to do the roast dinner with all the lard that used to sit
   around. You know, go to the butcher's and buy a whole lot of lard and
   put it in. And my parents lived until they were 91 (women, group 2).
    It was contended that lifestyles are different now; people still eat a lot,
but they do not 'bum' it up because of their sedentary occupations. Now
there is much more variety, but also more concem and anxiety around
food which was often related to the sheer diversity of food available.
Modem lifestyles were represented as urban, stressful and confusing,
redolent with anxieties around such aspects as diet and exercise, in which
it was considered very difficult to conform continually to the imperatives
of public health: 'our society is not as healthy as it was back in the days
when people grew their own stuff and they didn't eat all this processed
stuff that we buy (woman, group 9).
   Several participants expressed feelings of guilt and anxiety about eating
the wrong types of food, particularly fatty foods: 'a little bit of fat and I
feel guilty and I think, "oh geez, how much have I put on?"' (woman,
group 6). However, while it was clear that the participants were highly
aware of the health promotional orthodoxies around diet, and many of
them said that they attempted to conform to such advice, there was also
evidence of resistance to the imperatives of public health and medical
advice about diet. Several participants expressed their irritation and
annoyance about having their dietary choices dictated to them, and the
work and denial of pleasure involved in maintaining a *healthy' diet. For
example, one woman (group 4), a shift-worker at a large football club,
described how even though she had been 'really good' about not eating
fried foods such as chips, recently she had had a 'horrible night' at work,
and on her dinner break had felt the urge to eat chips. She gave into her
urge and felt the better for it: 'I thought, "oh to hell with it!" and I had
chips and gee, I enjoyed them!'".
® BlackweU Publishers Ltd/Edilorial Board 1995
                   Discourses on diet, cholesterol control and heart disease 487
   The complementary interpretive repertoires of 'control' and 'release',
as Crawford (1984) and Backett (1992) found in their studies, were there-
fore also evident in relation to these Australians' articulations of health
and diet. The participants argued that while it is important to exert disci-
pline in one's life in the interests of good health and an attractive (ie.
slim) appearan<%, it was also deemed necessary to be able to 'let go' and
to enjoy life, including eating the 'wrong' types of food, for 'a little bit
of what you fancy does you good' (Backett 1992: 267). It was asserted
that occasionally the constraints and stresses of life were such that food
served as a source of 'release', perhaps substituting for alcohol as a
means by which tensions and stresses could be alleviated. To be too
extreme about one's diet, without the ability to relax and enjoy oneself
now and again, was represented as being equally as wrong as being too
lax. Participants discussed the difficulties in maintaining rigid control
over diet and weight, even as they freely expressed censorial attitudes
towards those people who had 'let themselves go' (cf Backett 1992: 262,
Davison et al. 1992: 679).

Dealing with cholesterol

Most participants said they had first heard about cholesterol in the
media, typically locating the first such 'appearance' of cholesterol in the
early 1980s. Older people were more likely to have had a cholesterol test
and to know their 'score'. For example, one woman (group 6) could
recount the readings of several tests she had had over the years:
  I had one done in 1988 - oh, no it was 1987, or about 1987-1988. It
  was about 6.5. Then I had another one done in about 1990 and it had
  come down to about 5.8. Then the last one I had done was measured
  at 5.6.
   Those participants who had decided to have the test said that they did
so because it was a topical issue - 'flavour of the month', as one woman
(group 5) described it - because it was being offered free and they had
just decided to do it (for example, when giving blood), or because their
doctor had suggested it. There was evidence in some participants'
accounts of a desire to fulfil a curiosity about one's 'score' just for the
sake of knowing it, not necessarily because of a concern about one's
health. For example, one woman (group 8) had persoiaded her 77 year
old mother to have a cholesterol test for the first time, simply because she
had decided that 'it was time' her mother *had one done'. Other partici-
pants said that they had a family predisposition for heart disease and
high blood cholesterol readings and so were advised to have a cholesterol
test so that they could monitor their levels and engage in preventive
action such as controlling their diet.
                                         © Blackweil Publishers Ltd/Editorial Board 1995
 488 Deborah Lupton and Simon Chapman
    It was apparent from the participants' accounts that there are moralis-
 tic meanings associated with having a high blood cholesterol reading that
 are related to cultural assumptions about the relationship between physi-
 cal appearaiKe, health states and self-control. As a woman (group 1)
 commented, high blood cholesterol is 'associated with all these images,
 like of fat people, non-energetic peo^rie who sit around stuffing them-
 selves with cream cakes'. By contrast, having a 'good* (low) reading was
something to be proud of: as one man in group 10 commented of another
participant in the group, 'John is always boasting about his'. In the same
group, one man joked that another male participant must have high cho-
lesterol simply because of his appearance (because he was overweight): 'I
think that you have got high cholesterol just looking at you!'. The nega-
tive meanings associated with body weight, diet and cholesterol readings
are evident in such comments. It was assimied that there was a direct link
between body shape and cholesterol level. As Watson (1993: 248) and
Crawford (1984: 70-1) foimd, the grossly overweight person was cotisid-
ered the individual most likely to be 'unhealthy', or to have a high blood
cholesterol reading. Such an individual is deemed to have a spoiled iden-
tity' due to his or her inability to control diet and body weight (Watson
 1993: 249), and is deemed the archetypal 'candidate' for heart disease (cf.
Davison et al. 1991).
    Despite this propensity to blame overweight people for coiming high
blood cholesterol, most participants were aware of the complexity of the
cholesterol issue. For example, a man in group 3 talked about how he
had had his cholesterol tested twice in three days and the results varied
significantly, causing him to have doubts about the validity of the test.
Some people referred to 'good' and 'bad' cholesterol, others commented
that one's body manufactures cholesterol regardless of dietary intake, and
that a certain level of cholesterol is necessary to body functioning, while
members of group 8 discussed the relative merits of blood cholesterol and
triglycerides. A certain degree of confusion was evident in some accounts,
reflecting the conflicting nature of public discussion of cholesterol control
as well as the somewhat esoteric nature of the debate. For example:
   I think, I am sure that I have got it right, that everybody makes their
   own cholesterol - natural cholesterol - but natural cholesterol is not
   the dangerous one. I think that that is the way I understood it, as it is
   what you make yourself from what you eat that is the dangerous one
   (woman, group 4).
   It was pointed out in most of the discussions that some people are
lucky because they can over-eat because they are 'active' and 'bum ofP
the excess calories, or simply because they have a high metabolism.
Others put on weight easily and find dieting difficult. This may happen
even within the same family: 'my brother can eat what he likes and he is
as thin as a rake. I can't - as soon as I eat the wrong things I start to put
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                   Discourses on diet, cholesterol control and heart disease 489
weight on' (man, group 10). These observations of luck and chance in
relation to candidacy for heart disease were also translated in terms of
individuals' blood cholesterol readings. It was commonly noted that some
individuals, regardless of their ingestion of dietary cholesterol or fats,
simply manufacture high levels of cholesterol, while others may have low
blood cholesterol despite their 'unhealthy' diet. As one woman (group 8)
noted: 'but then some really thin people can have really bad cholesterol
can't they?'. This is viewed as a paradox because of the association com-
monly made in both public and private discourses between obesity, a
fatty diet and ill-health and between slimness and good health. Several
participants therefore commented that the likelihood of individuals suffer-
ing from heart disease or high blood cholesterol levels was not necessarily
related to their overt appearance and chosen lifestyle but was also possi-
bly 'in the genes' and therefore difficult to control or pr^ict.

Media coverage: who do you trust?

 A high degree of cynicism towards the news media's coverage of health
 and medical controversies was apparent in the interpretive repertoires of
 the focus group discussions. Participants observed that media coverage is
 sensationalised and 'over-kill'. They expressed their doubts as to the cred-
 ibihty of news accounts, and revealed their understanding of the reasons
 why newsmakers might attempt to sensationalise such issues. As one man
 (group 11) commented, 'I think that the media is a very big beat up.
 They will tell you one thing is good for you just to sell a magazine or sell
 the newspaper'. As a result, most people read the media accounts with a
 degree of suspended credulity: 'you only believe only half of what you
 read and half of what you hear' (woman, group 4). It was noted that the
media coverage may serve to support pre-existing views or that it may
simply be disregarded if one felt strongly enough about a certain food-
stuff. For example, one woman (group 8) described how she had recently
read an article in a wori^n's magazine arguing that liquorice was bad for
health. She had refused to take any notice of the article - 'I thought, no,
that's not true, they don't know what they're talking about' - simply
because she loved eating liquorice.
   Medical practitioners and researchers and health promotion authorities
were also subjected to criticism based on the confusing messages evident
in media accounts: 'even the most credible sources, like doctors, often
come out with the most ridiculous things' (woman, group 3). The ten-
dency of journalists to seek balance when reporting on controversial
issues by giving each 'side' an opportunity to defend its position, meant
that it was difficult for the reader to judge who was 'right', leading in
some cases, participants commented, to neither position appearing credi-
                                         O Blackweil Publishers Lid/Ediiorial Board 1995
490 Deborah Lupton and Simon Chapman
   If you read things that are totally contradictory from two so-called
   experts, you think, *God*, you know, 'where do these people get their
   facts from?'. You do wonder. You have to take it at, you know, face
   value a bit (woman, group 4).
   Other participants drew on discourses around the superior knowledge
of the medical and allied health professions, using their authority and
training in the areas as reasons to 'believe' their advice:
   We have to believe so much what all these experts tell us. And we
   believe that because they have got a letter after their name and they are
   supposed to know more than us. So we have to believe some of it
   (woman, group 4).
   However, when participants were asked 'who do you trust to get the
right advice?' they commonly drew upon an interpretive repertoire articu-
lating the integrity of their own bodies rather than drawing upon medical
authority as a strategy. Participants argued that you must trust yourself
and know in yourself, and that it comes down in the end to using one's
own commonsense and experience. For example, several participants
recoimted occasions when they had eaten certain foods and felt sick or
uncomfortable afterwards; thus, they had learnt from experience what
foods they should eat: 'you feel better when you are eating the better
things' (woman, group 2). If one's diet is 'wrong', one feels bloated, one's
skin breaks out, or one puts on weight. It was thus the 'wisdom of the
body' that helped people construct rules for everyday life:
   I think your body's the best judge (woman, group 1)
   If everyone is telling you different things, you have got to assess them
   for yourself. And your body is sure going to tell you when something
   is going wrong (woman, group 3).
  For some the solution was simply to eat what they liked, enjoy life and
not worry about the health benefits or deficiencies of their diet:
   You get one [media reportl telling you that cholesterol doesn't exist
   and one telling you that it does, but it's not bad and another saying it's
   going to kill you. In the end, you think, who cares? You continue
   doing what you do and live life to the full (woman, group 1).
  The adage ..'everything in moderation' was mentioned at least once in
almost all the groups as a strategy for dealing with inconsistencies and
confusions around food; for example, as one woman (group 2) cotnmented:
   It frustrates me because the pattern though my life is that [doctors] tell
   you it is good for you, then they tell you it is not. They tell you to do
   this, then they tell you not to. So you wonder who do you believe?
   Which is the right way to go, which is not? And I guess you basically
   have to think, everything in moderation.
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                    Discourses on diet, cholesterol control and heart disease 491

 It has been argued by some sociologists that the condition of late moder-
 nity is characterised by an increasing focus on and anxiety about risk
 (Beck 1992, Lupton 1993). The mass media and medical, scientific and
 legal institutions are integral to the definition and publicising of health
 risks. As many health risks are invisible or need technical knowledge to
 assess them, most individuals must rely on authorities from these institu-
 tions to interpret the meanings, import and implications of risks.
 However, unlike inany other issues and events that make the news, con-
 troversies around diet and health are issues that individuals, regardless of
 the extent of their medical or scientific knowledge base, can often weigh
 up using personal experience and lay knowledge.
     While the debate over the relative significance of epidemiological or
 clinical studies related to the use of cholesterol-lowering drugs or the
 effectiveness of dietary control for reducing the risk of heart disease may
 have been viewed by the majority of participants in the study as a matter
 for only those appropriately qualified to assess, a common tendency in
 the group discussions was to claim that participants' own experience in
 life and their lived experience of their own bodies served to provide them
 with guidelines for the conduct of dietary regimens. The participants said
 that they could observe the effects on their own bodies of certain dietary
 strategies or exercise regimens (or lack thereof), in terms of how they felt
 'in themselves' or by observing changes in their body shape. They tended
 to draw upon the repertoires of commonsense and 'everything in modera-
 tion', and their observations of others (friends and family members) as
 strategies to inform their response to the conflicting advice evident in
 media and health promotional texts conceming diet and heart disease.
There was evidence in the discussions of a certain fatalistic discourse,
relating to the fickleness of luck and chance and the role played by des-
 tiny (cf. Davison et al. 1992).
    The findings of the study therefore suggest that health promotional
orthodoxies, particularly if challenged by personal experience or news
reports of dissent, are subject to continued negotiation and challenging
on the part of members of the public rather than being accepted as
'truths'. Such reflexiveness has also been identified as a characteristic fea-
ture of the condition of late modernity, in which people struggle to recon-
cile different priorities, loyalties and beliefs around risk issues, and are
highly critical of the progressive ciaims of modernity (Beck 1992).
As found in the present study, while most people did not completely
relinquish their use of the knowledge claims of medical or epidemiological
researchers and practitioners to construct their understandings of the
issues, they were willing to be highly critical of both the disorder in the
ranks of these professions and the news media's propensity to use conflict
to attract audiences. The participants were sceptical of such claims, but
                                          © Blackwell Publishers Ltd/Editorial Board 1995
492 Deborah Lupton and Simon Chapman
also acknowledged that they had adopted some of the imperatives of
health warnings. For example, several participants said they had had a
cholesterol test and took the result seriously, especially if it was deemed
too high a reading. Most participants agreed that good health is pro-
tected by paying attention to one's diet, and said that they had changed
their diet to accord with health advice; by cutting down on fatty foods or
full-cream milk, for example.
   In the context of a society in which most people are expected by med-
ical and public health authorities to be knowledgeable and continually
self-monitoring of bodily states, it is not surprising that in the face of
conflicting advice concenung dietary and cholesterol control, individuals
have relied upon the repertoires of fate as well as the value of the lived
experience of one's own bodily reaction to dietary regimes. Most people
are placed in a somewhat invidious and ambivalent position, for there is
no easy path; the opportunity to question health promotional and med-
ical orthodoxies is problematised by a continuing dependence on medical
expertise to translate the 'meaning' of complex health risk controversies
and is limited by joumalistic conventions in framing these debates.
Address for correspondence: Dr Deborah Lupton, Faculty of Humanities
and Social Sciences. University of Westem Sydney, Nepean, PO Box 10,
Kingswood 2747, Australia.


This study was funded by a National Heart Foundation grant for 1993.


I The clippings used in the study were provided from the files of the Australian
  National Heart Foundation, which employs a commercial clippings service to
  collect all national news items relating to heart health.


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