Public Expressions of Trust and Distrust in Governmental Dietary Advice in Sweden

The Special Case of Trust in the Scandinavian Setting

People in Nordic countries stand out in cross-country comparisons of public trust. Such comparisons have found that Nordic people have a high degree of social trust and tend to consider corruption in their countries as not especially widespread; both these variables are important for the understanding of public attitudes to the welfare state (Rothstein, 2011). In Sweden, the National Food Agency, governed by the Ministry of Enterprise and Innovation, is the expert authority on food and nutrition. The agency has the task of providing dietary advice and promoting food habits that would meet basic nutritional needs and prevent diseases across the entire population. Although publishing and disseminating dietary guidelines are two small tasks among all the responsibilities of the agency (Mattisson et al., 2012; Regeringskansliet, 2009), they form a key means of engaging with the public. The Swedish process of publishing dietary guidelines is relatively open and members of the public are invited to have a say during the process. However, responses to the latest Swedish update of dietary advice (2015) came predominantly from industrial stakeholders with vested interest in influencing the guidelines (Bergman et al., 2018). The National Food Agency is known among most people and has a mostly positive public image (S. Holmberg & Tryggvason, 2014). In a national survey on public administration in Sweden, 67% of respondents reported awareness of the National Food Agency; half of those who were aware of the agency said the agency managed its tasks well, and a 10th of them said the agency managed its tasks badly. Notably, public administration was rated in very similar ways regardless of the respondents’ social, demographic, or economic background (S. Holmberg & Tryggvason, 2014). In the National Food Agency’s own evaluations in 2011 (n = 1,000), only 20% of respondents said they had not heard about the agency’s dietary advice (Enghardt Barbieri, 2013). These findings suggest that the National Food Agency retains high levels of recognition and that public trust in the agency is relatively high. It is important to note, however, that authoritative nutritional experts and the National Food Agency have been challenged for more than a decade, especially by the Swedish Low-Carb/High Fat (LCHF) Movement, which is led by bloggers (Gunnarsson & Elam, 2012). Similar devaluation of traditional expertise has also been expressed in social media by LCHF-proponents in Finland (Jauho, 2016). Recently, in Norway, the trustworthiness of national dietary advice and the research behind it have been subject to public debate between researchers and governmental representatives, with particular attention to guidelines concerning fish consumption. Critics accused the Norwegian Directorate of Health of publishing guidelines based on research financed by the salmon industry and dismissing environmental toxicity studies that opposed their advice. The national guidelines were framed by critics as advancing market interests at the expense of children and pregnant women, whom the guidelines, according to these critics, placed at risk (see, for example, Bolann & Bjorke Monsen, 2018; Eggesbø, 2018).

Trust in food, and in the institutions that ensure food safety, has been studied mainly in the context of food scandals and scares, such as disease outbreaks, contamination with toxic substances and genetically modified organisms (GMOs) (Kjærnes et al., 2007). However, engagement between lay people and authorities concerning advice on healthy food habits in everyday settings has not been studied extensively. National advice on healthy eating is fundamentally based on biomedical research focusing on the health effects of foods and nutrients as well as on measurable adherence to those guidelines. Nevertheless, to understand peoples’ engagement with food, we also need to consider sociological and relational aspects. Our aim is, therefore, to explore the relation between lay people and the National Food Agency in Sweden, by examining lay people’s written correspondence with the authority on food habits and healthy eating.

Material

Data were obtained from letters sent electronically (by e-mail and web forms) to the National Food Agency between April 27, 2015, and December 31, 2016. This period was chosen because on April 27, 2015, the National Food Agency launched an updated version of its dietary guidelines aimed at communicating healthy and sustainable food habits to the public in Sweden (Brugård Konde et al., 2015). Thus, collecting letters sent during the time immediately after the guidelines’ release allowed us to capture public concerns about these updated guidelines; lay people’s concerns about healthy eating in relation to the National Food Agency were of particular interest.

The Swedish National Food Agency is charged with overseeing food safety, promoting healthy food habits and ensuring fair food trade practices. The agency operates through regulation and control as well as recommendations and communication (National Food Agency, 2015). Questions posted by the public to the National Food Agency are registered and categorized in a database by agency personnel. The database includes four main categories: control and regulation (approximately 3,500 posts in 2016), food and health (approximately 3,100 posts in 2016), opinions and comments (approximately 150 posts in 2016), and other (approximately 150 posts in 2016). Each main category includes a number of subgroups and sub-subgroups to choose from, to categorize the subject of each question. In the present study, letters were collected from two of the main categories—“Food and Health” and “Opinions and Comments”—and from the subgroup “Nutrition.” The subgroup “Nutrition” included 11 sub-subgroups, of which four groups (“General Dietary Advice,” “Food Habits,” “Nutritional value,” and “Other”) included questions of interest for this study. Letters concerning other parts of the National Food Agency’s functions, such as toxicology and regulating functions, were not collected.

The selected categories included, in total, 1,339 letters. Letters sent for professional or educational purposes, letters concerning specific conditions (such as diseases or pregnancy), and letters about technical problems on the website were excluded. Letters that had been sent by regular mail were registered in the database but were not accessible, and thus could not be included. The analysis, then, included 727 letters sent from lay people (Table 1). The length of the letters ranged from one simple sentence to several pages of text. Some letters also included copy-pasted articles to which the letter-writers’ questions referred; these article texts were used in the analysis to enhance our interpretation of the letter-writers’ concerns and questions.

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Table 1.

Categorization and Numbers of Public Letters to the National Food Agency, April 27, 2015, to December 31, 2016.

Main Category	Subgroup	Sub-Subgroup	Letters in the Database	Letters Included in the Analysis
Food and health	Nutrition	General dietary advice	386	250
		Food habits	75	26
		Other	204	79
		Nutritional value	630	333
Opinions and comments	Nutrition	General dietary advice	35	33
		Food habits	9	6
Total			1,339	727

Data for this study were requested based on the Swedish principle of public access to official records (SFS 1949:105) last modified by SFS 2014:1370. As these letters are public documents, no informed consent was required to access them. This study was conducted as part of Bergman’s doctoral research, and she collected the letter texts manually (through copying and pasting) during visits to the National Food Agency. Letters were collected at two separate time points; the first collection was made during June 2015 and the second collection from January to March 2017. The study was approved by the Swedish Regional Ethical Board in Uppsala on September 16, 2015. To protect the confidentiality of letter-writers, all quotes are presented anonymously and all identifying details have been omitted from the quotes. The original quotes in Swedish have been translated by the authors and reviewed by a bilingual colleague.

Analysis

The material was analyzed using thematic analysis methods (Braun & Clarke, 2006). Similar approaches of thematically analyzing lay people’s written accounts have been used to elucidate people’s experiences of illness (Rawlings, Brown, Stone, & Reuber, 2018). A preliminary analysis of the data was conducted by Bergman, based on an initial smaller sample of letters, and was then refined through a complete analysis of the entire sample of letters. During this preliminary phase, Bergman gathered the letters from the National Food Agency database and gained a primary understanding of the material, with a focus on identifying the types of concerns expressed by letter-writers. All letters in the initial sample were then read through and sorted, to be included or excluded, as described in the Materials subsection. After a second reading of the included letters, initial codes were developed, based on the concerns expressed in the letters and how they were framed. The initial codes demonstrated that a considerable number of the letters expressed concern through questioning or casting doubt on the National Food Agency. This was the first step to identifying meaningful patterns in the data, to be presented in themes that interpret the data (Morgan, 2018). Bergman then revisited the initial codes, categorizing the findings into two initial themes of trust and distrust. The qualitative Software package NVivo 11 was used in the process of coding the letters. The initial themes were then presented together with example quotes, to coresearcher Persson Osowski. After agreement was achieved, Bergman collected and analyzed the total sample of letters, and elaborated the themes further, using a framework of trust and distrust in expert authorities, which was developed in discussion with coresearchers Eli, Persson-Osowski, Lövestam, and Nowicka. The themes were then revised and agreed upon by all coauthors, forming four thematic categories of ways in which letter-writers expressed trust and distrust in the National Food Agency.

“Confirming and Clarifying”

Trust was tacitly expressed in letters that turned to the National Food Agency as a source of reliable, expert answers. By asking simple questions to ascertain correct eating and food preparation choices and to clarify the official recommendations provided for healthy eating, letter-writers demonstrated confidence in the agency’s authoritative role. For example, letter-writers turned to the National Food Agency for support on questions of how to find food rich in certain nutrients, what to eat, and how much to eat. These letters were the shortest. Although many questions were framed as relating to food choices, much of the focus was placed on food components:

Do blueberries lose any of their nutrients if I mix them in a blender with water and drink it instead of eating them whole?

As in the quote above, many letter-writers wanted to make sure they prepared and handled foods in a way that preserved as many vitamins and minerals as possible. They contacted the National Food Agency as an expert on the nutritional impact of different preparation and preservation methods, for example, mixing or microwaving foods.

Although the vast majority of questions expressed general concerns about food, some letter-writers asked for clarifications about specific advice:

In the text on your webpage you speak about legumes and I think that is good. You mention beans, lentils and chickpeas, but not Swedish yellow peas, which are common here. Do yellow peas count in your recommendation for 500 grams of vegetables per day?

These types of letters acknowledged the official recommendations without questioning their trustworthiness. The questions posed by the letter-writers were sometimes accompanied by a personal account of food habits or ways of handling and preparing foods. However, references to other sources of information were sparse. Together, these letters conveyed an uncomplicated framing of National Food Agency as the authority best placed to distinguish between “right” and “wrong” food and eating practices.

“Seeking Support and Arbitration”

Some letter-writers, while expressing trust in the National Food Agency, displayed a more complex understanding of information concerning food and healthy eating, engaging with multiple sources and opinions. Referring to food-related information read or heard in the course of everyday life, they turned to the National Food Agency as a source of reliable answers. These letters were characterized by a short account of an informational dilemma, followed by the question “is this correct/true?” In these letters, the National Food Agency was framed as an arbitrator, vested with the authority to sort out “facts” from “myths”:

Hi! A colleague sent me some vegan propaganda saying that everyone has been deceived that “milk is healthy.” (Link)

I guess you have heard this before. By referring to a vegan website as a source saying that dairy products are harmful to humans, I hold as reliable as using Jehovah’s Witnesses as a source to prove that the evolution does not exist . . . By all means, some things can surely be partly true. For example, the possibility of increased risk for some forms of cancer has been broadcasted in the media lately. But bone fragility? It sounds rather stupid anyways . . . but irrespective of how stupid it sounds—how is it actually, what is correct? If anyone ought to know, it is for sure you!

The letters demonstrated the everyday difficulty of negotiating food-related recommendations, debates and discussions, and how to distinguish between reliable and questionable information. Concerns were not only about what to eat but also about what food to avoid so as not to harm the body. For example, this letter-writer sought clarity on perceived risks and assurance about the number of eggs that was safe to consume in a given day:

Hi

Since I was a child I have heard this and that about eggs and that it is dangerous to eat a lot here and there. I have googled a lot, but I have not found an answer that satisfies me. So I thought I would turn to those who know the best!

How dangerous is it to eat eggs every day?

And is it dangerous when I eat 2-3 eggs?

Can I have more than, e.g., 6 eggs per day?

I work out, both cardio and weight training 5 days a week and eat pretty healthy food 6/7 days and have one “cheat” day when I can eat whatever I want. My partner is very worried over [my diet], the eggs in particular, so of course I want to get it clear on paper to show her what is “right” and “wrong.”

As in the quote above, concerns about potentially harmful foods or substances in food reflected ongoing, society-wide discussions on risky foods and food substances. The letter-writers’ understanding of health-related questions were formed by a variety of messages and everyday social encounters, such that the National Food Agency was cast as a safe and reliable institution amid an informational cacophony.

In addition to questions on mainstream foods and issues such as milk and egg consumption, some letter-writers turned to the National Food Agency with concerns over “new” foods:

Hi, I have tried to find out what health effects chia seeds have when you eat and drink them whole and soaked, but the information I find is contradictory. Does anyone at the National Food Agency know the health effects of eating soaked chia seeds?

This letter exemplified writers’ expectations that the authority of the National Food Agency would extend to all possible food-related issues, old as well as new, and that the agency would be updated on new food trends. Some letter-writers also offered suggestions on how the National Food Agency could provide up-to-date advice, by sharing their own experiences and ideas. Other letter-writers expressed more general concerns, for example, about the health status of the Swedish public or how health is governed in society, and contacted the National Food Agency as a discussion partner to debate on these questions. In these letters, rather than provide a final authoritative answer, the agency was invited to have a say on questions of moral, rather than practical, resonance.

“Questioning and Scrutinizing”

Critical letter-writers questioned the work of the National Food Agency and its advice, typically with direct reference to scientific (or pseudoscientific) sources. These letter-writers sought to know how the official recommendations were produced, often asking for the scientific references used to support certain statements or the dietary guidelines as a whole. Although presenting credibility concerns, the tone in these letters was principally respectful. The letter-writers asked questions such as “What studies do you want to refer to that support this?” and “Is there any scientific reference for . . .?” or made statements such as “I am really interested in what studies are behind your recommendations,” “I would like to get access to that research,” or “Grateful for references to scientific publications that prove . . .” Some expressed themselves with more skepticism: “. . . if the statement is true, there should be one best study to declare. Which one/ones is it?” The main question posed by these letters was “did the National Food Agency really stand behind its faulty recommendations?” Letter-writers, while expressing eagerness to see the scientific references employed by the National Food Agency, were also eager to refute recommendations or statements by referring to scientific work: “The result from a study . . .,” “As far as I know there are no studies confirming this . . .,” and “Attached you find a study . . . that ought to be known by the National Food Agency.” Letter-writers referred to own experiences of reading research reports or other sources which led them to the conclusion that the agency published outdated advice. Links to opposing advice or scientific research were provided, together with questions calling for the National Food Agency to comment on this opposing advice. Some letter-writers also pleaded with the agency to change official advice, suggesting that otherwise the agency—from the point of view of the letter-writers—would lose its remaining public trust:

Hi! I have followed your homepage for a long time and disappointingly I see that you keep on sharing old, faulty dietary advice with people who want to lose weight. For a long time I have wondered, if your dietitians or food experts listen to new science? Just because at one time point you studied to be a dietitian or food expert with the evidence of that time, it does not mean that it [the knowledge you learned] is correct and will never change. Since your job, to a large extent is about food issues, you surely keep track of what has happened in recent years regarding new knowledge that naturally occurring saturated fat is not as harmful as believed earlier, but rather, it is all these carbohydrates and especially those fast carbohydrates and sugars in different forms that make people fat and sick. My question is: Why do you not reconsider your advice to people when more and more doctors and professors are doing that?

As in this quote, letter-writers expected the National Food Agency to be aware of new scientific evidence for healthy eating and expressed frustration at the agency for presumably choosing not to incorporate new findings into its guidelines. In these letters, official advice was framed as faulty and out of date and also, in some cases, as posing a hazard to public nutritional health. Although most of these letter-writers referred to debates about carbohydrate, protein, and fat recommendations, some letter-writers focused on debates concerning plant-based diets. They argued that the National Food Agency made it sound unreasonably hard to follow a vegetarian or vegan diet, and that the agency’s promotion of milk was an example of its outdated approach to dietary advice.

“Protesting and Fighting”

Protesting letter-writers objected to the kind of advice given by the National Food Agency, using harsh, accusing tones to convey their objections. These letter-writers accused the National Food Agency of being lazy, ignorant, deliberately uninformed, and totally out of date with its advice. The letter-writers expressed their frustration, and sometimes rage, through emotional language. Letters were filled with rebukes such as “this is scandalous,” “I’m shocked,” “this is totally sick,” “[y]our ignorance is alarming,” “you were unlucky when thinking,” “you should be ashamed,” and “are you totally blind.” Some letters concluded with exhortations such as “do it again and do it correctly!” and “[t]hink differently, think newly!”

These letter-writers seemed convinced that no reliable scientific basis was provided by the agency to prove its dietary advice and that, instead, the National Food Agency endorsed an old-fashioned “fat scare” framing of healthy eating. To challenge the agency, letter-writers included links to blogs, articles, and YouTube clips as examples of updated dietary advice, or as evidence of the faultiness of official dietary advice:

Have you seen the film, normal daily diet, generates 40 teaspoons of sugar. (Link to a film called “the sugar film”)

The film about children who eat according to your recommendations. (Link to a TV program about sugar in children’s food)

WHO considers that your recommendation of 10% sugar to be decreased to 5%. (Link to a newspaper article)

Additionally, you do not count the sugar that normally occurs in our diets, why not count that? Carbohydrates are carbohydrates. The most recent research compares fructose with alcohol which can lead to a fatty liver. (Link to a popularized article about fatty liver), read under the picture of the pile of sugar.

And this with your fear of fat. (Link to the Swedish “Dietdoctor”)

Why can you not see that you are all wrong? When are you going to open your eyes?

Think again about all of the money you could save from diabetes and obesity care in our country, if you only dared to investigate this. But, then we have the pharmaceutical industry, think about all of the money they will lose. As I understand many of your experts have connections to the industry, how do you make sure that there are no conflicts of interest?

People cited as authorities in letters like the one above were often public opponents of the National Food Agency and proponents of alternative diets such as the LCHF-diet represented by the Swedish “Dietdoctor.” Although letter-writers based their arguments on popular sources such as blogs, they also cited scientific references to dispute the agency’s dietary advice or demanded to be shown the scientific evidence behind the National Food Agency’s advice. Letters also expressed suspicions and accusations that the authority was corrupt and entangled with the economic interests of industry, questioning who funded the research that the agency cited as objective and reliable.

As in the quote above, many critical letter-writers said the National Food Agency was “blind” and needed to “open its eyes,” accusing the agency of endangering public health through ignoring the “facts.” These letter-writers portrayed an image of a public in increasing need of health care because of so-called “lifestyle diseases,” at the expense of taxpayers. In some cases, they insinuated or outwardly proclaimed that National Food Agency personnel were failing to work for their tax-payer-funded salaries, calling on the National Food Agency to “be ashamed.”

To further strengthen their points, some letter-writers also shared information about their own experiences of achieving better health through opposing the National Food Agency’s dietary recommendations in practice, arguing that these personal examples should be shared for the public good:

Who decides that butter is dangerous and margarine is good?

I had a heart attack two years ago, and after that I was prescribed pills to lower my cholesterol. I also got strict guidelines about food: low-fat food, only margarine and lots of carbohydrates . . . all mumbo-jumbo . . . who can say that is good?

Since about one year ago I only use BUTTER, eat bloody steaks, less carbohydrates . . . and see I feel much better than I have in years. So please make sure everyone involved gets access to this link, it would save a lot of suffering if it became public knowledge. (Link to a low-carb-high-fat propagating blog)

As in the letter above, some letter-writers described animal fats and proteins as healthy and natural, while depicting the National Food Agency’s advice as promoting processed and artificial food. Natural fat, like butterfat, was frequently invoked as an example of a nutritious, “healthy” alternative to “dangerous” processed fats—in this case, margarine—which the National Food Agency’s advice treated as equivalent. The letter-writers’ ideas about what constitutes healthy food were thus not in accordance with the National Food Agency, although they similarly employed arguments about healthy nutrients. Another issue the letters invoked was the danger of “hidden” sugars, found in foods recommended by the National Food Agency. To support these claims, the letter-writers consistently turned to sources they depicted as the most recent research and expert voices about food and health.

Some letters criticized the National Food Agency for failing, in their view, to fulfill its responsibility for governing diets on a population-level scale. Letter-writers contacted the agency with exhortations on how it should manage dietary risks, urging the National Food Agency to restrict and forbid certain foods or food components:

Hi. I have two questions I want adequate answers to.

1. Why is there no action about hidden sweetening in food? Sugar/Sweeteners should not occur in basic food items. Moreover, they should be minimized in all food items. It [sugar] is NOT necessary at all. YOU NEED TO SANITIZE THIS SLOPPY JUNGLE!

2. Why is acrylamide allowed in food items? It is carcinogenic and therefore harmful, most importantly for children! Also, in this case this poison should be completely prohibited in all food items!

IF NOT: Warnings are needed on packaging!

These letter-writers demanded that the National Food Agency inform, warn, forbid, or regulate the consumption of certain foods through taxes or restrictions. According to these letter-writers, action was needed to “save” the public from illness, even death. Notably, despite this critique, the letters framed National Food Agency as the authority responsible for society-wide issues associated with food and health, especially sugar consumption, as well as obesity and other so-called lifestyle diseases.

Strengths and Limitations

As letters are written in socially organized ways, our use of letters as data has enabled us to analyze “naturally occurring” texts that reflect broader currents of societal discourse around food, eating, and governmentality. Thus, the data were not affected by researcher bias or study design (Bowen, 2009). Moreover, as all letters were written in Swedish, we can be confident that the letters represented concerns and approaches specific to Sweden’s food and nutrition context. We consider the use of naturally produced text an asset, but at the same time recognize the possibility that letter-writers did not know their correspondence with official agencies would become public documents. It is possible that letter-writers would have expressed themselves differently had they been aware that their letters would be made public. Finally, as the letter-writers’ sociodemographic information was not available, it is impossible to know the extent to which they reflected the general population of Sweden.