Education And Debate

Exploring a fiscal food policy: the case of diet and ischaemic heart diseaseCommentary: Alternative nutrition outcomes using a fiscal food policy

BMJ 2000; 320 doi: (Published 29 January 2000) Cite this as: BMJ 2000;320:301

Exploring a fiscal food policy: the case of diet and ischaemic heart disease

  1. Tom Marshall, honorary clinical lecturer (
  1. Department of Public Health and Epidemiology, University of Birmingham, Birmingham B15 2TT
  2. a Office of Research, Education, and Economics, US Department of Agriculture, 1400 Independence Ave NW, Whitten Building, Room 217W, Washington, DC 20250, USA
  3. b Economic Research Service, Office of Research, Education, and Economics, US Department of Agriculture, 1800 M Street NW, Room 4145, Washington, DC 20350, USA
  • Accepted 10 May 1999

Diet determines cholesterol concentrations, and cholesterol concentrations determine the prevalence of ischaemic heart disease. This paper explores the potential effects of fiscal measures on diet and ischaemic heart disease. There is a clear economic rationale for this approach: the correction of market failure caused by externalities. Externalities are said to occur when some of the costs of consumption are not borne by the consumer. When ischaemic heart disease strikes, there are costs to the community (productivity losses or indirect costs) and to the health service (direct costs). A case can therefore be made for using taxation to compensate for the external costs of an atherogenic diet.

Summary points

Current dietary patterns are partly responsible for the high risk of ischaemic heart disease in Britain, in particular among low income groups; these dietary patterns are reinforced by the material constraints of poverty

Pricing of foodstuffs encourages the purchase and consumption of a cholesterol raising diet, particularly among people with tight food budgets

By extending value added tax to the main sources of dietary saturated fat, between 900 and 1000 premature deaths a year might be avoided

The additional tax revenue could finance compensatory measures to raise income for low income groups

Econometric and health policy research should investigate the effects of price changes on diet and health

Diet, cholesterol concentrations, and ischaemic heart disease

The relation between diet, serum cholesterol concentrations, and ischaemic heart disease is relatively well understood. In individuals, serum cholesterol concentrations—or more specifically, the ratio of low density lipoprotein to high density lipoprotein—are a major determinant of the risk of ischaemic heart disease. Serum cholesterol concentrations are largely determined by the proportion of dietary energy derived from saturated or polyunsaturated fats and by dietary intake of cholesterol. The Keys equation (box), which has recently been corroborated, describes this in a simple mathematical relationship.1 3

The Keys equation

Change in …

Correspondence to: E Kennedy

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