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SERIES                             An unsuitable and degraded diet?                             Part one: public health le...
Public health lessons from the mid-Victorian working class diet    Ethical approval     historical and the scientific pers...
Journal of the Royal Society of Medicine         contributor was     consider afresh the concept that it was indeed       ...
Public health lessons from the mid-Victorian working class dietHistorical-nutritional context                          ing...
Journal of the Royal Society of Medicine                         looked at more inclusive secondary sources38 and         ...
Public health lessons from the mid-Victorian working class diettheir ability to work and survive. The next paper       A c...
Journal of the Royal Society of Medicine                         References                                               ...
Public health lessons from the mid-Victorian working class diet60 Elia M, Stratton R, Russell C, Green C, Pan F. The cost ...
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An unsuitable and degraded diet? Part one: public health lessons from the mid-Victorian working class diet


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An unsuitable and degraded diet? Part one: public health lessons from the mid-Victorian working class diet

  1. 1. SERIES An unsuitable and degraded diet? Part one: public health lessons from the mid-Victorian working class diet Paul Clayton1 + Judith Rowbotham2 1 School of Life Sciences, Oxford Brookes University 2 NottinghamTrent University – School of Arts and Humanities, Clifton Lane, Nottingham W8 7NP UK , Correspondence to: Paul Clayton. E-mail: DECLARATIONS Introduction to the series wide range of types of primary source material, as discussed in this first paper. This in itself has pro- Competing interests Principal findings vided a high degree of internal cross-checking of PC provides the validity of the historical data. It has been con- The research resulting in this series of three papers consultancy services sidered necessary due to the reality that extensive (further papers to be published in succeeding issues to a number of of JRSM), drawing on a range of historical datasets quantitative data for the Victorian age, in formats companies in the viewed through the lens of current scientific under- recognized by today’s scientific statisticians, do food and drink, standing, indicates that cultural and other biases not exist. Consequently, it could be argued that supplement and have distorted the historical record, leading to con- our perspective (like the conclusions based on pharmaceutical clusions which test many current health policy Rowntree et al.2) lacks representativeness and sectors, including assumptions about a steady improvement in British historicity. However, the full range of sources we Coca Cola Ltd, nutrition since the nineteenth century. As these have consulted provides the best possible survey papers show, the urban mid-Victorians, including of dietary habits, in ways that counterbalance the Univite Ltd, Biothera the working classes, ate a notably good diet, includ- consciously biased records of surveys like those of Pharma. JR is a ing significant amounts of vegetables and fruit, Booth3 and Rowntree2. We have re-examined the historian who which enabled a life expectancy matching that of urban (as distinct from the rural) mid-Victorian provides no today. We follow the example of George Rosen (a working class diet and its nutritional values by consultancy services looking in detail at typical food consumption pat- public health practitioner, and in his time editor of to anyone on any terns of the time. The use of a qualitative approach the American Journal of Public Health and Journal of commercial basis, is thus not a weakness but a real strength, giving the History of Medicine, among others), in believing but provides that a historical dimension is essential to a sound insights into life experience that cannot be readily academic comment perspective in public health today.1 deduced from quantitative statistics. The other to media and author is a pharmacologist and pharmaconutri- academic outlets, tionist, who has drawn on the fullest possible including Woman’s Methods, strengths and weaknesses range of scientific and medical data to interpret the Hour, European A strength, but also a weakness, of these papers is historical material: his work is apparent through- Social Science that they are not purely medical studies. They are out but is most fully discussed in the final paper. History Conference, based on genuinely interdisciplinary research and In providing this challenge to assumptions etc. as such cannot be tested in the usual ways for about the steady improvement in British nutri- studies appearing in this, and similar, journals. tional history since the mid-nineteenth century, Funding The authors revisited the historical record because however, the authors acknowledge that historical No funding or of the mismatch between the assumed content of materials cannot provide the fully testable data sponsorship was the Victorian working class diet and adult life normally considered essential to medical studies. sought or obtained expectancy. They then cross-referenced this Yet we argue that the historical data used, and the material against current scientific/medical knowl- methodologies employed to interrogate it, are edge, using primarily a range of studies already in appropriate to both science and social science, as the public domain and so supportable by a wealth the development of the argument that follows will of scientific papers to reach their conclusions. explain in detail. Inevitably, in the limitations of a Amongst their strengths is the breadth of the short series it is impossible to rehearse all the his- research drawn on and the widely-tested nature of torical data drawn upon. However, that incorpor- the scientific data in particular. One of the authors ated in these papers was identified on the basis of is a historian experienced in data collection from a historical typicality and connotations for both the282 J R Soc Med 2008: 101: 282–289. DOI 10.1258/jrsm.2008.080112
  2. 2. Public health lessons from the mid-Victorian working class diet Ethical approval historical and the scientific perspectives. In this of McKeown’s work,6,7 thereby restoring the Not appropriate or series we present, respectively, analyses of mid- emphasis on public health and medical interven-relevant: all modern Victorian levels of physical activity, dietary intakes tions. Should this have led to a wholesale rejectiondata cited is already and public health patterns. The significance of our of McKeown? We argue that there is one areain the public domain, findings and their relevance to health care design where his thesis has considerable merit: that relat- and all historical and delivery today are integrated and developed ing to nutritional standards, which in turn rehabili- data is either in the third paper, together with suggestions for tates his claim for an improved adult life future research. In this first paper, the issue of expectancy in the period after 1850, a claim sub- anonymized or Victorian life expectancy is revisited in the context stantiated by later detailed statistical studies.8 To untraceable of contemporary health policy. this we add the concept that to life expectancy was Guarantor also added health expectancy. PC A significant source of error is the established Introduction to part one view is that the mid-Victorian urban poor ate an Contributorship Current expressions of concern about national lev- inadequate diet that contributed to increased mor- This series of three els of ill-health from government and leading bidity; and that consequently, medical advances papers was jointly health figures, often focusing on the nutritional and post-1880 environmental sanitary improve- conceived and value of the nation’s diet, are not original in either ments were the crucial factors in expanding liferesearched. JR took motivation or substance. The importance of diet as expectancy. In terms of reducing perinatal mor- primary a determinant of health was first recognized by the tality, the role of modern medicine from c1890 responsibility for state in the mid-nineteenth century because of was central; but we argue that this does not hold pressure from leading scientific and medical fig- true for improvements otherwise. Improvements searching out both ures of the day. One of the leading protagonists in in adult life expectancy are discernable by the the primary entrenching the concept of a medical dimension to 1861 census, when figures show that by com- historical sources public health policy thinking was John Snow, parison with the 1841 figures, twice as many men and the relevant and women per 100,000 births had an average Medical Advisor to the Privy Council under the secondary governments of Lords Aberdeen and Palmerston. expectation of a further 20 years of life.8references; PC took Governments continue to rely upon this dimen- The concept of a short, because malnourished, primary sion in developing public health policies. life has been promoted by numerous historians, responsibility for We contend, however, that serious historical, making assumptions about the nutritional value of searching out the methodological and class-based biases about indi- the mid-Victorian urban working class diet.9–11 scientific and vidual diet as a source of nutrition, dating back to Sources for such scholars include reports from medical data. The the Victorian era, have been integrated into the nineteenth century philanthropists like Fanny general tenor and public health model used today, and are now con- Calder, who believed that the working classes ate tributing to unnecessary ill-health and premature an ‘unsuitable and degraded diet’,12 and from conclusions of the death because they have obscured the debate medical commentators like William Farr, seeking papers (including about the relative merits of dietary guidance, to relate what he saw as the flaws in the working the exercise of intervention and individual responsibility. The class (and particularly the workhouse) diet to drawing up dietary purpose of this three-part series is to revisit the causes of death, especially among infants.13 patterns and levels dietary patterns of those with the least money and, Agenda-driven studies of poverty like Booth3 of physical activity supposedly, the worst health in the mid-Victorian or Rowntree2 have also been influential in which are era; to illuminate the historical biases that have establishing a belief in consequent nutritional summarized in the subsequently been integrated into twenty-first inadequacy.14 first and second century public health policy; and to suggest In revisiting the issue of mid-Victorian urban papers) are a joint ways in which the contemporary diet could be nutritional standards and returning to the Mc- effort, representing improved. Keown thesis, we have a clear focus on the mid-50% input from each Nineteenth century public health policy Victorian period, from c1850 to c1877–80. Rather focused on reducing mortality rates.1 Seeking to than taking the established view of an ongoing contributor. While explain what he correctly identified as an improve- dietary improvement during the Victorian era, our comment on ment in life expectancy, Thomas McKeown sug- analysis suggests the reverse: that mid-Victorian penultimate drafts gested that an improved working class diet was nutritional standards were significantly better was sought from likely to have improved resistance to infectious than generally realized, and then declined to a specialists in both diseases.4 For him this, rather than public health nadir at the end of the nineteenth century, making the historical and interventions or medical improvements, explained that date a highly misleading starting point for scientific/medical the first improvements in morbidity rates.5 Demo- illustrations of twentieth century nutritional fields, no other graphic historians subsequently challenged much ‘progress’. Consequently, there is a need to J R Soc Med 2008: 101: 282–289. DOI 10.1258/jrsm.2008.080112 283
  3. 3. Journal of the Royal Society of Medicine contributor was consider afresh the concept that it was indeed and the effects of intemperance were the most directly or dietary improvement via affordable available common causes of ill-heath and death.21 This is substantially foodstuffs, rather than public health and medical amply borne out by the public health records of the involved in the advances, which had the most positive influence time, which clearly promote the role of disease and writing of these on the quality of working class health. accident as the main causes of mortality.8 The only papers or the This has considerable implications for the common disease supposedly related to malnutri- research thereof. present public health model, rooted as it is in medi- tion was rickets22 but increased incidence of this cal (pharmaceutical and surgical) intervention and disease in the early Victorian period was largely Those cited have moral exhortation. We argue that the lessons of the due to decreased exposure to sunlight among been cited where mid-Victorian period indicate that the most (cost-) the urbanized working classes.23 Paradoxically, the contributors effective way of maintaining and improving pub- a re-classification of rickets as a primarily nutri- judged that their lic health today is to promote standards of nutri- tional disorder in the 1920s24 contributed to work was relevant tion via facilitating informed individual choice and exacerbated subsequent received views of and supportive, or and educational strategies, rather than legislation Victorian malnutrition.25 where we wished to and medical intervention. Victorian misinformation underpins current identify work that we There has been some development in this direc- misconceptions. Much concern about nutrition wished to challenge tion in the state-managed push for ‘five portions of then was rooted in middle-class disapproval of fruit and vegetables per day’. But it leaves the way that the working classes supposedly Acknowledgements untouched the vexed question of whether a ‘sensi- ‘wasted’ food.26 Public health commentators We acknowledge ble balanced diet’ is achievable today without the believed that freedom to buy what they wanted gratefully the additional intervention of supplements and/or was ‘bad’ for the working classes; that they did comments made by fortification programmes, given current levels of not know what was ‘good’ for them nutritionally, BJ Harris, Professor physical activity, food consumption patterns, and nor how to cook what they did buy.26,27 Middle- of the History of the nutritional content of many modern foods15 class views were also influenced by the food Social Policy, compared to those of the past. In this series we seek adulteration scandals of the time (see the second University of to improve comprehension of this reality through paper in this series), which affected all consumers an exploration of the mid-Victorian diet and public but the working classes most severely. These Southampton. Any health profile. were associated with the Victorian laissez-faire errors now are Much is made today of Victorian reports of indi- approach to business, but it is only fair to point solely the viduals so poor they died from starvation. It was out that there are almost identical concerns today responsibility of the undoubtedly an issue in the 1840s, appositely about food content and composition, labelling authors. We also labelled the ‘Hungry Forties’. By the end of that and advertising.28 Victorian food adulteration with to thank Mike decade, however, a real improvement in the econ- was rightly a high-profile issue, arguably Lean, Professor of omics of the working classes had taken place. amounting to a ‘moral panic’;29 but its extent is Human Nutrition, Measures such as the repeal of the Corn Laws in unclear and assumed incidence should be bal- University of 1846 signalled the beginnings of the age of afford- anced against the evidence for a diet-based Glasgow, for his able food. The impact on the health of the poor was improvement in working class health. (The often early input swift.16 It is our argument that not only the dangers intemperate media coverage of dietary issues and of starvation were avoided, but also the dangers to their implications for lifestyle and health provides adult life expectancy associated with malnutrition, an interesting parallel today!) because by 1850 the working class diet had Prejudices about class and diet unduly influ- improved markedly in terms of both quality and enced first Victorian writers and policy-makers quantity. reflecting on health, then those who have cited Between 1850 and 1870, deaths attributable to them uncritically thereafter. They are still used as a starvation and malnutrition accounted for around basis for modern public health models.8,30 But 1.5% of reported causes of death in urban con- by taking a wider range of sources into account we ditions, though malnutrition undoubtedly contrib- have reassessed the diet of the mid-Victorian poor; uted to other causes of morbidity and mortality, concluding (in contrast to received wisdom) such as increased vulnerability to infection.17 that the majority ate a diet vastly superior to However, these figures are not significantly higher that generally consumed today, one substantially than occur today.18,19 The comments of regular in advance of current public health recom- visitors to the poorest quarters of Britain’s cities in mendations. Reverting to the nutritional essentials this period underline the comparative rarity of of the mid-Victorian diet and lifestyle would death from starvation alone;20,21 instead, they materially improve human well-being in Britain noted that infectious illness, brutality, accident today.284 J R Soc Med 2008: 101: 282–289. DOI 10.1258/jrsm.2008.080112
  4. 4. Public health lessons from the mid-Victorian working class dietHistorical-nutritional context ing the need to provide school meals for working class children, reinforced the idea that the urbanFrom 1877, historians generally agree that food working classes were not only malnourished at thecosts fell as much as 30% due to imports of cheaper start of the twentieth century but also (in a leapbasics such as cereals and meat. As a result, sup- which seemed logical then and has ever since) thatposedly, ‘the first really appreciable nutritional they had been so since the start of the nineteenthimprovement . occurred’.31 Imported American century’s industrial urbanization.34wheat and modern milling techniques reduced the A detailed re-reading of Victorian sources,price of flour, while fresh and tinned meat arrived however, reveals that diet and public healthfrom the Argentine, Australia and New Zealand. reached a high point in the mid-Victorian era, toCanned fruit and milk became more widely avail- decline noticeably at the end of the 1870s with theable. These changes increased the variety and introduction of the first generation of processedquantity of the working class diet, and was adver- foods. The increased sugar intake alone causedtised as reducing the opportunities for adultera- such damage to the nation’s teeth that many peo-tion.31 Simultaneously, cheaper sugar promoted ple could no longer chew tough foods, therebythe huge increase in sugar consumption (in confec- reducing their intake of vegetables, fruits andtionery, processed foods like evaporated milk, and nuts.35fruit canned in heavy sugar syrups) from the 1880s That some mid-Victorians (especially womenon. Consequent assumptions about what has been and children but also seasonal workers at adverselabelled an ‘improvement’ in food quality between times) were malnourished is indisputable; but in1877 and 1889 have led to the conclusion that pre- this paper we contest the claim that it was aviously, the value of the working class diet must majority experience. Rather, we suggest that thehave been even worse, and that since malnutrition first generation of processed foods, far fromwas so widespread at the end of the century, it improving the late Victorian urban workingmust have been almost universal at the mid- class diet, ‘degraded’ it to the state observed bycentury. Rowntree in 1901;2 and that prior to this in the This ‘progressive improvement’ conclusion, period c1850–1880, the working class diet was farhowever, is at odds with the evidence. Mid- superior. While a substantive mass of VictorianVictorian navigators (navvies), who as seasonal quantitative data is not available, our sources com-workers were towards the bottom end of the econ- pensate for this in their range and depth. Theyomic scale in terms of their purchasing ability, include details (including statistics) provided bycould (when in work) routinely shovel up to contemporary sources from official sources such as20 tons of earth per day from below their feet to Blue Books, Reports from charitable organizations,above their heads;32 an enormous physical effort Mayhew’s London Labour and the London Poor,20that most modern workers would be totally unable and information in medical texts and dietariesto emulate, and one that required great strength, from workhouses, hospitals and army records. Westamina and robust good health. Yet after 50 years drew on depictions of purchase, cookery and con-of supposed ‘nutritional improvements’, the Brit- sumption in contemporary fiction and periodicals,ish army recruiting for the Boer war at the turn of including authors like Dickens with his detailedthe century found around 50% of young working descriptions of the consumption strategies of theclass recruits to be so malnourished as to be unfit mid-Victorian poor. We also investigated infor-for service.14,33 This was a rapid decline. The mation from more neglected datasets, notablyrecruiting sergeants had reported no such prob- Victorian cookery books and diet advice for thelems during the Asante (1873–4) and Zulu Wars poor, where recent studies have also confirmed(1877–8). Twenty years later, there is evidence of a their relevance.27 This information (when inte-precipitous drop in nutritional standards: the grated with the other sources) can give a moreinfantry were forced to lower the minimum height nuanced picture of working class diets and itsfor recruits from 5 4$, where it had remained fairly values.constantly since 1800, to 5 in 1901. (Army recruits Walton, reviewing Oddy’s From Plain Fare toup to the 1870s were generally drawn from the Fusion Food, noticed the absence of working classbetter-nourished rural population: thereafter they voices therein, and added, fairly, that we cannotwere mainly from the urban working class.) trust the official records on working class diets, In 1903, and as a direct result of the Boer disas- because in recounting what families and individ-ter, the government set up the Committee on uals consumed there was likely to be self-Physical Deterioration. Its 1904 Report, emphasiz- censorship.36,37 We recognize this, and have J R Soc Med 2008: 101: 282–289. DOI 10.1258/jrsm.2008.080112 285
  5. 5. Journal of the Royal Society of Medicine looked at more inclusive secondary sources38 and Victorian calorific intakes also oral accounts where they exist for this period. It is also why we amplify these with sources It is not just the composition of the mid-Victorian including fiction, periodicals, and records like diet that is so distinct from our own, but also the London Police Court Mission reports. We draw on amount of the food typically consumed. Due to the typical (and so cross-referential) ‘throwaway’ levels of physical activity routinely undertaken comments in these sources, contextualizing them by the mid-Victorian working classes, calorific with data on food supply chains, food availability requirements ranged between 150–200% of today’s and pricing, and retailing practices,39–42 to give a historically low values. Almost all work involved composite overview of dietary patterns and a more moderate to heavy physical labour, and often realistic estimation of the mid-Victorian working included that involved in getting to work. Seasonal class diet. and other low-paid workers often had to walk up Important and relatively costly staples in the to six miles per day.47 While some mid-Victorian working class diet (meat, bread, potatoes) are the working class women worked from home (seam- key known constituents of the mid-Victorian stressing for instance), more went out to work working class ‘food basket’: but detailed study as domestics or worked in shops, factories and reveals that they were used as headline cost indi- workshops, necessitating long days on their cators of consumption. They were not the only feet, plus the additional burden of housework.47,48 foodstuffs consumed in significant quantities. Men worked on average 9–10 hours per day for Because many commonly consumed ingredients 5.5–6 days a week, giving a range from 50–60 hours were not considered sufficiently costly to count as of physical activity per week.48 Factoring in the part of even a poverty diet, they often went unre- walk to and from work increases the range of corded; their consumption being taken for granted total hours of work-related physical activity up to by all sides. One woman, when quizzed by the 55–70 hours per week. Women’s expenditure of Charity Organisation Society in 1877 to explain her effort was similarly large.48 While women also had budget for a cheap rice-based dish to feed her housework to do, male leisure activities, including family of ten ‘What would the onions and the fat gardening and informal football, also involved that you put in the rice cost? You did not put that substantial physical effort. down at any cost’, responded ‘hardly a half- Using average figures for work-related calorie penny’.43 There is extensive informal evidence consumption, men required between 280 (walk- indicating the major role played by vegetables ing) and 440 calories (heavy yard work) per hour, (especially onions), fruit (especially cherries and with women requiring between 260 and 350 calo- apples), and items like bones, dripping, offal and ries per hour. This gives calorific expenditure meat scraps in the mid-Victorian diet; but little in ranges during the working week of 3000–4500 the official record simply because these foods were calories/day (men) and 2400–3500 calories/day so cheap that housewives took their purchase (women). Total calorific requirements were likely largely for granted44–46 to have been even higher during the winter Yet the myth of widespread malnutrition per- months. With less insulated, poorly-warmed sists. According to Wohl, modern study locates the homes, working class mid-Victorians used more calorie consumption of the average Victorian calories to keep warm than we do. The same held working class adult at a mere 2,099 per head; while true for workplaces, unless the work (certain an intake of at least 3,770 calories represents the factory operations, blacksmithing, etc) heated amount then needed to undertake strenuous work the environment to equally demanding unhealthy and stay healthy.10 These figures are self-evidently levels. At the top end of the physical activity incorrect, as on this negative calorific balance these range were the navvies, building (largely with- average mid-Victorian working adults would not out machinery) the roads and railways that have been able to work, procreate or indeed sur- enabled the expansion of the British economy, and vive, as many did, into a surprisingly healthy old when in work, expending 5000 calories or more age. His figures assume that the diet consisted per day. largely of carbohydrates and fats and fail to take into account calories regularly derived from fish, Dietary summary meat and plant foods. If the calorie count is so obviously fallacious, what does this say about the Clearly mid-Victorian working class men and rest of the commonly held assumptions about the women must have consumed between 50 and mid-Victorian diet? 100% more calories than we do today to maintain286 J R Soc Med 2008: 101: 282–289. DOI 10.1258/jrsm.2008.080112
  6. 6. Public health lessons from the mid-Victorian working class diettheir ability to work and survive. The next paper A case for supplements?argues that their diet was rich in vegetables andfruits, with consumption of these amounting to In marked contrast to this, modern diets are rich inaround eight to ten portions per day. It also con- processed foods, have a higher sodium/potassiumtained significantly more nuts, legumes, whole ratio, with less fruit, vegetables and wholegrains.grains and omega three fatty acids than the They are lower in fibre and phytonutrients, in pro-modern diet. Much meat consumed was offal, portional and absolute terms; and, because of ourwhich has a higher micronutrient density than the high intakes of potato products, breakfast cereals,skeletal muscle we largely eat today.49 These confectionery and refined baked goods, are likelyfactors ensured far higher intakes of micro- and to have a significantly higher glycemic load. Givenphytonutrients than are consumed today. Prior to this, and our low calorific throughput, it followsthe introduction of margarine in the late mid- that we are more likely to suffer from dysnutritionVictorian period, dietary intakes of trans fats (multiple micro- and phytonutrient depletion)were very low. There were very few processed than our mid-Victorian ancestors were; this is nowfoods and therefore little hidden salt, other than being referred to as Type B malnutrition.55,56 Thisin bread. Recipes also suggest that significantly is supported by survey findings on both sides ofless salt was added to meals. At table, salt was not the Atlantic; the USDA’s 1994 to 1996 Continuingusually sprinkled on a serving but piled at the Survey of Food Intakes by Individuals,57,58 and theside of the plate, allowing consumers to regulate National Diet and Nutrition Surveys59 both showconsumption in a more controlled way. In that many individuals today are unable to obtaingeneral, the mid-Victorian diet had a lower Reference Nutrient Intakes (RNI) values – or evencalorific density and a higher nutrient density the Lower RNI values – of a variety of vitaminsthan ours. It had a higher content of fibre (includ- and minerals. Malnutrition in the UK is now reck-ing fermentable fibre) and a lower sodium/ oned to cost in excess of £7.3 billion per annum.60potassium ratio. In many respects, therefore, it The authors believe that, since it would be unac-resembles the dietary recommendations made ceptable and impracticable to recreate the highby today’s advocates of the paleolithic diet, but calorie mid-Victorian working class diet, this con-has the critical advantage of extensive Victorian stitutes either a persuasive argument for a moredocumentary evidence. widespread use of food fortification and/or food In terms of alcohol consumption, the compari- supplements, not only in hospitals and in long-sons with today are particularly revealing. Many term care facilities but in the community; and acontemporary reports suggest that around a fifth review of agricultural subsidies to make locallyof mid-Victorian working class men might, when grown fruit and vegetables cheaper.employed, spend up to a fifth of their income onbeer.50 Assuming an average urban income rang-ing from £1–4 per week, and given mid-century Conclusionpub prices of 3d upwards per pint for beer,51 thereported expenditure would account for around Contrary to received wisdom, the mid-Victorian16–20 pints per week maximum or between three working classes appear to have been followingand four pints per night. As mid-Victorian beer modern advice about healthy lifestyles almost togenerally had an alcohol content ranging between the letter. Not yet having acquired the taste for1–3.5%,52 this is equivalent to 1.5–2 pints of beer processed foods, they were in fact eating some-per day in contemporary terms. Seen in this light, thing closer to the Mediterranean diet or eventhe enormous Victorian concern about drunken- the Paleolithic diet than the modern Western diet.ness in the working classes appear to be more a This should have created enormous public healthreflection of respectable morality than a real public benefits; or, at the very least, very significantlyhealth issue.53 Cost implications ensured that, for reduced levels of degenerative disease, in an inter-most, the mid-Victorian ‘alcohol problem’ was cer- esting reflection upon the McKeown thesis. Thattainly less significant than it is today, when the this was indeed the case, at least for the mid-frequency of public inebriation and levels of injury Victorian period, will be demonstrated in the fol-and illness have become a serious public health lowing papers of this series; the second in theconcern.54 Finally, mid-Victorian tobacco con- series analyses mid-Victorian dietary patterns insumption was very much lower than today, and greater detail, and the third correlates the nutri-their levels of physical activity were, as described, tional pharmacology of the mid-Victorian dietmuch higher. with contemporary health records. J R Soc Med 2008: 101: 282–289. DOI 10.1258/jrsm.2008.080112 287
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