It wasn’t until the next morning that I found out what the story was - Salford council are proposing to ban takeaways near schools from selling “hot food over the counter” before 5pm – allegedly to encourage children to eat healthily.

Perhaps recognising that this would be a vote loser among existing takeaway owners, the ban is proposed to affect new outlets opened within 400m of a school.

Councillor Margaret Morris said that “public health and helping to reduce obesity levels” was a “top priority” for the council. The council is planning to encourage takeaways to offer well promoted healthy alternatives.

What would I have said on the sofa?

There are a number of points that could be made about this story:

1) Councillors should stick to running councils and leave obesity to people who know something about this.

2) Why pick on takeaways? When I’m in my nearest town, Caldicot, I see more children locally in newsagents, off licenses and the post office – buying sweets and soft drinks – than I do buying the relatively more expensive fish and chips or in the pie shop. Three of the the biggest advertisers are Coca-Cola, Mars and Walkers – that’s what kids are after near the school gates.

3) Surely children up to the age of sixth form (I have no idea what these new year numbers are) are not allowed off the premises to visit takeaways at lunchtime? In which case, this applies to the top two years – 16-18 year olds. This group of young people can drive half way through this age group – a) this means they can go anywhere to get junk and b) it means we have to start trusting them to make their own decisions. Students who stay on past GCSEs can vote at some stage in their final year of school. Is Salford planning a region where their A Level students can choose their Prime Minister, but not their next meal?

If under 16s have money and freedom to buy takeaways on the way home from school (4-5pm period) then there’s not much the council or schools can do about this. Perhaps if they had better teaching about what healthy eating is and a better school lunch, they wouldn’t want a takeaway or a Mars Bar on the way home.

This brings me on to what my main point would have been…

Salford school lunches

Salford school lunches are provided centrally, so the menu is also posted centrally on the internet.

You will probably find your own school’s menu on line – they seem to be proud of what they are providing, which beggars belief.

If you click on the link you will be able to download a word file with a three week menu timetable. Here’s Week 1:

You can look at weeks 2 and 3 – the contents are very similar – starch, starch and more starch. Below each menu is a note that “Wholemeal bread must be available daily.” More starch.

In week 1, main meal options include: quiche and chips (and baked beans) for Monday; Indian takeaway on Tuesday; pie and potatoes for Wednesday; pizza and chips on Thursday and fish and chips (and baked beans) on “Fun day Friday”. Only they don’t call the meals what I’ve called them. This is how Salford lunch providers try to make their meals seem healthy:

Monday’s quiche and chips is described as “Homemade Cheese Quiche with Oven Baked Herby Diced Potatoes and Salad or Baked Beans.”

Tuesday’s Indian takeaway is “Chicken and Sweet Potato Tikka Masala with Patna Rice and Naan Bread.”

Wednesday’s pie and potatoes is “Homemade Meat and Potato Pie with Carrots.”

Thursday’s pizza and chips is “Homemade Hawaiian Pizza with Oven Baked Potato Wedges, Salad and Coleslaw.”

Friday’s fish and chips is “Fish Fingers with Garden Peas or Baked Beans, and Oven Baked Chips.”

The other weeks are no better of course. The days that don’t have chips have pasta and/or bread  - the latter always being available.

“Fun day Friday” week 2 has two options: a) a breaded chicken burger with chips or b) sausage roll, baked beans and chips.

Homemade is worthy of a PR company – pizza is pizza and pie is pie. Don’t give me oven baked nonsense either – chips are chips whether they are baked on vegetable oil or fried in vegetable oil.

OK, if the sixth former went out for fish and chips, s/he would probably get a larger portion (actually, s/he’d probably just buy the chips – fish in batter is expensive). At school, however, there is a daily choice of two desserts – called “sweet treats”. That will be the junk segment on the government eatbadly plate being followed. Overall, therefore, the school dinner pupil could get more junk than the takeaway visitor.

“Sweet treats” are: chocolate crunch with vanilla sauce or biscuit with fruit on Monday; cake or flapjack with fruit on Tuesday; ice cream or biscuit with a milkshake for Wednesday; crumble and custard or biscuit with fruit on Thursday and then cake or biscuit with fruit on “Fun day Friday”.

Week 3 choices are more pasta, more bread, more chips, more potatoes, more cakes, more biscuits, more milkshakes, more puddings…

And Salford council wonder why 35% of 10 and 11-year-olds in Salford are overweight or obese.

Salford council needs to stop trying to grab media headlines with an empty stunt like this and take a serious look at their own menus – if they genuinely want to do something about obesity in their area.

Another 5:2 diet was being researched before the Horizon programme. Michelle Harvie was the lead author on a paper published in the International Journal of Obesity in May 2011. The full article is available here .

This blog was posted on 22nd April 2013. I received an email from Michelle Harvie on 24th April requesting some amends. We have had a few email exchanges since and any changes to the original blog are in red below.

The Intermittent Fasting Study

The study involved 107 women who were randomly assigned to either a Continuous Energy Restriction (CER) diet or an Intermittent Energy Restriction (IER) diet. To quote from the article: “The CER group were prescribed a daily 25% restriction based on a Mediterranean type diet (30% fat, 15% monounsaturated, 7% saturated fat, 7% polyunsaturated fatty acids, 45% low glycaemic load carbohydrate, and 25% protein). The IER group were asked to undertake a Very Low Calorie Diet (VLCD) (75% restriction) on 2 consecutive days and to consume estimated requirements for weight maintenance for the remaining 5 days according to the nutrient composition above.”

The Very Low Calorie Diet (VLCD) part of the intermittent group’s diet provided approximately 500 calories per day. It was low carb as well as low calorie – delivered in the form of 2 pints of semi-skimmed milk, approximately 300g of vegetables, 1 portion of fruit, a salty low calorie drink (why?!) and a multivitamin and mineral supplement.

Participants in both groups were advised to maintain their current activity levels throughout the trial, and did not receive specific exercise counselling. Energy prescriptions were reviewed throughout the trial to account for changes in weight and exercise levels to maintain a 25% restriction below estimated requirements for weight maintenance.

If we assume that an average woman in each group needed 2,000 calories a day and assume for simplicity that this did not change during the trial, then the average woman in the CER group would need 14,000 calories per week and would receive 10,500 – a sustained reduction of 25% per day. The average woman in the IER group would need 14,000 calories per week and would receive 11,000 – a reduction of 1,500 calories on 2 days. Thus the weekly calorie intake and deficit would be essentially the same. (Notwithstanding everything I write about the type of calories being far more important than the number).

Results

107 women started the 6 month study. 18 women withdrew from the study before completing the 6 months: 11 from the intermittent group and 7 from the continual restriction group. Did the starve-for-2-days group find the diet more unbearable therefore?

Here is the passage reporting the results verbatim from the study:

“Weight loss was comparable between the groups. LOCF [Last Observation Carried Forward] analysis at 6 months showed weight reduced from mean (95% CI) 81.5 (77.5 to 85.4) kg to 75 (71.2 to 78.8) kg in the IER group compared to a reduction from 84.4 (79.7 to 89.1) kg to 78.7 (74.2 to 83.2) kg in the CER group. The percentage of women in the IER and CER groups losing 5–10% body weight were 30 and 33% respectively, and losing 10% or more body weight were 34 and 22% respectively (χ²=1.89, P=0.39). Both groups experienced comparable reductions in body fat, FFM [Fat Free Mass], hip, bust and thigh circumference and composition of weight loss. Percentage of weight lost which was fat in the IER and CER groups was 79 (±24) and 79 (±26) % respectively (P=0.99).”

Removing the statistical details for ease of observation, the above passage tells us:

-        “Weight loss was comparable between the groups.”

-        “Both groups experienced comparable reductions in body fat…”

-        At 6 months, the IER (intermittent) group had reduced on average from 81.5kg to 75kg. The CER (continuous) group had reduced on average from 84.4 to 78.7kg. Both groups lost approximately 6kg on average, equating to approximately a 7-8% reduction from starting weight.

-        That’s 1 kg a month. That’s 2lb a month. Hardly justifying the Daily Mail headlines “The diet revolution that’s swept Britain.” If I starved for 2 days a week and never ate more than normal on the other 5 days, or cut back 25% every single day for 6 months, I would want significantly more than a 0.5lb a week weight loss. The record weight loss for The Harcombe Diet (Phase 1) is 17lb in 5 days. I would be astonished if someone didn’t lose more in 5 days of Phase 1 than in 2-3 months of the average on this diet and with far fewer rules and restrictions.

As Dr. Margaret McCartney noted in this clip from Radio 4′s Inside Health (listen from approximately 20 minutes into the programme) – the clinical trial “didn’t show any difference.” Quite so.

Despite the poor results in this clinical trial, the diet has been published in a book called “The 2 day diet”. (This last sentence was wrong – as you will see below – this 2011 article was not the diet in Harvie’s book). It was serialised in the Daily Mail from the 11th February 2013 onwards for a week. These articles are not available on line (to make you buy the paper and/or the book). Another serialisation started in the Daily Mail on Saturday 20th April – again – the details of the diet are not available on line.

Harvie states “The most important point is that our 2 day diet book is not based on the original milk and fruit and vegetables (650 kcal) diet which was reported in the Int J obesity in 2011. This was a proof of principle study showing that 2 day diets could work.”

This was most enlightening, as it discounts the 2011 study as being able to play any part in the “clinically proved” claim of the 2 day diet in the book. I’ve left the study in this blog, for interest, (not least to show how poor the weight loss is), but it plays no part in claimed clinical proof.

Harvie goes on to say “The book is based  on our improved low carb 2 day diet, and the  statistics used to support the weight loss reported in the book have come from our recent publication in the British Journal of Nutrition.” (BJN henceforth)

I have had an email exchange with Harvie challenging the claim that the diet in the BJN is the 2 day diet in her book. She stands by the claim and states “The diet in the book is the  diet inn (sic) the aper (sic). The diet showed significant reductions in fat which is what we claim for the book.”

However, I cannot see the evidence for this (I have a copy of the full paper). The paper compares three diets – two involving what is called “Intermittent Energy and Carbohydrate Restriction” (IECR) (my emphasis) and one involving “Daily Energy Restriction”. The paper states “The IECR and DER interventions involved an overall 25% energy restriction… Participants randomised to IECR were asked to restrict energy and carbohydrate on two consecutive days each week (70% energy restriction and 40g carbohydrate) and to consume a euenergetic Mediterranean-type diet that met estimated energy requirements for the remaining 5d of the week. Restricted IECR days provided between 2500 and 2717kJ…”

2500-2717kJ is 597-649 calories. The intermittent diet reviewed in the BJN study was both calorie and carbohydrate restricted. Taking just the protein and fat servings for a woman in the restricted days of the 2 day diet (the diet is detailed below), and looking just at calories, a woman could have 12 medium eggs and 35 grams of olive oil (choosing just two foods to keep the analysis simple – the different foods allowed are unlikely to be significantly different in calories per serving size) and these alone (before the dairy, fruit, veg, mints) would add up to 1,065 calories. Indeed in another part of her correspondence Harvie says “The restricted days often end up self limiting to around 1000 kcal i.e. a 50% and not starving yourself.”

You can’t have it both ways. The diet in the book is not the diet in the paper. The diet in the book has not, therefore, been clinically proven.

Notwithstanding this, the BJN paper did not claim any significant difference in weight loss between the diets. “Both IECR groups experienced significantly greater and comparable reductions in body fat than the DER group, but no significantly greater reductions in weight.” Harvie makes no claims for weight advantage in her email to me when she states “The diet showed  significant reductions in fat which is what we claim for the book.” However the back cover of the book states “Lose more weight and twice as much fat as on a standard calorie-controlled diet – then keep it off forever”. The last part is also unproven – a month’s maintenance followed the three month diet and a check at four months following baseline is the latest assessment recorded by the study. Significantly this is two months before the well-documented six month regain observed with calorie deficit diets.

Before you get excited about the fat claim – the intermittent dieters (having approximately 600 calories a day for 2 days a week remember) lost an average of 3.7kg of fat in 3 months. That’s just over a couple of pounds a month. A month – not a week.

We should also make the point that neither the 2011 nor the 2013 paper study men. Both study women. Hence there can be no claim that either intermittent diet reviewed by Harvie/Howell has been clinically proven for men, notwithstanding that the diets for women in the journal articles were different in both cases and neither the same as the one in the book.

The authors

The book authors are Michelle Harvie – a dietician and Tony Howell – Professor of Oncology. Together they run Manchester University’s Genesis Breast Cancer Prevention Centre.

The Claims

The front cover of the book has the words “clinically proven.” The Daily Mail February serialisation majored on the claim “clinically proven to reduce weight.” The “clinically proven” refers to the article in the International Journal of Obesity.  Despite the fact that weight loss overall was low and there was no difference between the intermittent diet and the continuous calorie deficit diet, because this was done as a study the authors are able to make the “clinically proven” claim. (As per the probably unintentionally helpful intervention from Harvie above – I can see no evidence that any clinically proven claim can be made.)

“Clinically proven to lose you an average of a couple of pounds a month over 6 months” would be more accurate. “Clinically proven to do no better than normal dieting” would have been another option.

Stopping at 6 months is also interesting as all evidence from Keys (1945) to Franz (2007) to Weight Watchers (2010) shows regain starting at approximately 6 months after starting a calorie deficit diet. The 5:2 diet has not been clinically proven to achieve sustained weight loss.

Breast Cancer

The Daily Mail got into misleading territory in the February serialisation. Here is a direct quotation from the article on 11th February 2013: “In a study of 34,000 women, Dr Harvie and Professor Howell were the first to discover that being overweight significantly increases your risk of breast cancer and that losing just 5 per cent of your body weight and keeping it off is enough to reduce your risk of breast cancer by a staggering 40 per cent.”

First, were Harvie and Howell really the first to discover that being overweight significantly increases the risk of breast cancer? Really? Here’s a study I found in a quick search dating back to 1993. Did Harvie and Howell produce a study before this?

Harvie says “For the record we weren’t the first group to report that being overweight significantly increases your risk of breast cancer, but were the first to  report  that losing just 5 per cent of your body weight and keeping it off is enough to reduce your risk of breast cancer by 25- 40 per cent within the Iowa Women’s Health Study”. 

It is not an absolute truth that losing 5% of your body weight and keeping it off can reduce your risk of breast cancer by 25-40%. A study may have found an association, not causation, of a relative, not absolute, risk. If this is the study being referred to, there were 1,987 incidents in over 440,000 person years of follow up. That’s a 0.45% chance of an incident in any study year. That’s why I get annoyed when researchers dramatise/scare people with relative risk headlines. The absolute risk is difficult to even conceive.

Secondly, if the observation is that a 5% sustained weight loss reduces the risk (remember, this will be relative risk, not absolute) of breast cancer, then any diet that achieves weight loss could claim to reduce the risk of breast cancer. Here’s my suggested headline: “The Atkins diet reduces the risk of breast cancer.”

The Mail (Feb) continued “Their diet, which is clinically proven to be more effective than conventional dieting.” This is simply not true. The 2011 journal article stated quite clearly ” Weight loss was comparable between the groups.”

The Diet

The Mosley 5:2 diet advises that the days should not be consecutive. The Harvie/Howell diet says that the 2 days should be consecutive. The Harvie/Howell diet claims that there is no calorie target on the 2 days – just foods that you can’t eat. You’re joking of course! There is a directive for fat to be eaten, carbs to be eaten and protein to be eaten – with portion sizes spelled out and these portion tables by macro nutrient are dictated for the ‘non-diet’ days as well as the ‘diet-days.’

The concept sounds simple enough” Spend two consecutive days each week enjoying protein (fish, meat, eggs) and vegetables but no carbs (potatoes, bread, pasta) and then stick to a ‘healthy Mediterranean-style diet’ for the other five days.”

This is the reality:

These are the numbers and sizes of the protein, fat and carb portions that you are allowed on DIET DAYS:

PROTEIN: a maximum of 12 servings for women and 14 servings for men.

1 portion = 30g/1oz oily fish; skinless chicken; lean beef, pork, lamb or offal.

1 rasher lean bacon; 1 egg

50g of tofu.

60g white fish.

45g/1.5oz of seafood/tuna in brine.

FAT: maximum of 5 servings for women and 6 servings for men.

1 portion = 8g margarine (avoid buttery types), 7g olive oil, 3 walnut halves or 8 peanuts, 8g peanut butter; 10 olives; 15g low-fat mayo.

DAIRY: Men & women 3 servings.

1 portion = 1/3 pint skimmed/semi-skimmed milk/soya milk; 3 tablespoons diet yoghurt; 2 tablespoons normal yoghurt; 30g/1oz reduced fat cheese.

FRUIT – Men & women 1 serving.

1 portion = 80g/2.5oz portion of low carb fruit (apricots, berries, rhubarb etc)

VEG/SALAD: 5 servings.

1 portion = 80g/2.5oz of low carb veg (green beans, asparagus, broccoli, cabbage etc).

TREATS – sugar free gum?! up to 10 sugar free mints!

DRINKS – At least 2 litres a day of water, tea, coffee or other sugar-free or low-calorie drinks.

This confirms that a dietician and a professor don’t know one macronutrient from another. Protein is in everything except sucrose (table sugar) and oils. All the foods listed under protein are combinations of fat and protein (fish, meat, eggs). Some of the ‘proteins’ contain carbs as well as protein and fat (lentils, beans).

Harvie asked me to correct for the fact that “we do not allow lentils, beans and baked beans on restricted days.” I am happy to correct this and have deleted those entries under the restricted days above.

Harvie states that she and Professor Howell “do know one macronutrient from another” and that the protein, fat and carb food lists represent the main ingredient of those foods.

Harvie and Howell may well know one macronutrient from another, but they don’t know the main macronutrient in lentils, beans and baked beans. 100g of boiled lentils has 0g fat, 9g protein and 20g carbohydrate. The remainder is water/ash. 100g of boiled beans has 0g fat, 9g protein and 23g carbohydrate. The remainer is water/ash. 100g of cooked baked beans has 0g fat, 5g protein and 20g carbohydrate. Carbohydrate is the main macronutrient in all three of these examples given.

Under fats, margarine and olive oil are fats. Nuts and avocado contain carbs, fat and protein in good measure. And what on earth are a dietician and a doctor doing advising hydrogenated (or interesterified), bleached, deodorised, emulsified, coloured and fortified margarine in preference to natural, nutritious butter? And what on earth are a dietician and a doctor doing advising low calorie, sweetened, drinks as part of a healthy diet. Have they not googled “the dangers of aspartame”?

(I was being a bit tongue in cheek here, as 99% of doctors and dieticians sadly promote interesterified, bleached, deodorised, emulsified, coloured and fortified margarine over natural, nutritious butter and don’t seem to know the harm that aspartame can inflict – Harvie and Howell are just no different). Harvie has asked me to point out “We have summarised the most up to date evidence based research on asparatame and saturated fat in the book, and not all the hype and anecdotes and personal viewpoints which may appear on Google.” The book has two paragraphs on sweeteners, covering aspartame among others. Of the many dangers associated with aspartame it lists one – blood cancer – and thus recommends limiting intake of diet drinks to no more than nine cans per week!  

On saturated fat, there is no evidence that Harvie and Howell know that meat has more unsaturated than saturated fat. They make the common recommendation to cut down on meat to reduce saturated fat and to replace saturated fats with ‘healthy’ fats, especially monounsaturated fats. There is more unsaturated fat than saturated fat in meat (red, white, whatever) and the main single fat in meat is (with the odd rare exception) monounsaturated. The book also claims that “saturated fats clog arteries.” Ha ha – only if you intravenously inject them!

NON-DIET days (Puh-lease!)

“You are basically eating a healthy Mediterranean diet with lots of fresh fish, meat, salad, vegetables and whole grains” say the authors. Please see this blog for the never ending nonsense about the Mediterranean Diet.

These are your food allowances on non-diet days. How the heck is this not a diet?!

Men (max servings)

Women (max servings)

Serving sizes of protein and fat are as for the diet days.

The carb servings for the non-diet (ha ha) days are as follows. You are advised to “always choose wholegrain.”

1 portion = 3 tbsp whole wheat cereal; 1 weetabix; 1 heaped tbsp oats; 1 slice wholemeal bread; 1/2 roll; 2 rye crispbreads; 1 oatcake; 2 heaped tbsp cooked pasta; 1 lasagne sheet; 1 small potato; 2 tbsp sweet corn kernels.

The small print

“Do not do this diet as a child, teenager, pregnant, breastfeeding, suffering from an eating disorder. The high protein may post problems for those with kidney disease or at risk from kidney disease. Diabetics – seek advice.”

The final word

The Friday 15th April Daily Mail article described the diet as “It’s gloriously simple”!

Hello?!

I love maths, but I would lose the will to live even trying to work out one so-called non diet day of the triple simultaneous equation that would be my carb/fat/protein number and size of portions – even allowing for the fact that the diet doesn’t know fats from proteins or carbs.

This is a 7 day diet, delivering barely a quarter of the calorie intake needed on 2 days of the week. That’s 30% of your life starving and 100% of your life on a diet – counting portions and measuring out 80g of vegetables. (As noted above, Harvie states that “The restricted days often end up self limiting to around 1000 kcal i.e. a 50% and not starving yourself” – proof that this is not the approximately 600 calories intermittently in the BJN article).

Don’t do it!

This is obsessive and miserable and it’s proven to lose an average of 0.5lb a week – if you stick to the diet for 6 months. Then we don’t know if you will regain. I can confidently forecast that you will need to stay on this kind of restrained eating for life or you will regain – you will have trained your body to maintain on a lower calorie intake.

Or you could just eat real food (meat, fish, eggs, dairy, vegetables, fruits in season and whole grains in moderation); three times a day and get on with your life. But then that would be The Harcombe Diet!

The article led to the usual sensational headlines across the world – the BBC; CBC News Canada; The Herald Sun in Australia and so on. The article itself claimed “We estimated that 3.3% of deaths could be prevented if all participants had a processed meat consumption of less than 20 g/day. Significant associations with processed meat intake were observed for cardiovascular diseases, cancer and ‘other causes of death’. The consumption of poultry was not related to all-cause mortality.”

The study details

The European Prospective Investigation into Cancer (EPIC) study is being conducted in 23 centres in 10 European countries (Denmark, France, Germany, Greece, Italy, Norway, Spain, Sweden, The Netherlands and The UK). Participants were recruited between 1992 and 2000. At recruitment men were 40-70 and women were 35-70 years old. The number of participants at baseline was 448,568.

Median follow-up time for this study was 12.7 years. During the follow-up period 26,344 participants (11,563 men and 14,871 women) died. Of these 5,556 deaths were from cardiovascular disease, 9,861 cancer, 1,068 respiratory disease, 715 digestive tract disease and 9,144 other causes.

The dietary questionnaire grouped the foods relevant to this study as follows:

Red meat (beef, pork, mutton/lamb, horse, goat);

Processed meat (“all meat products, including ham, bacon, sausages, small part of minced meat that has been bought as a ready-to-eat product”); and

White meat (poultry, including chicken, hen, turkey, duck, goose, unclassified poultry and rabbit).

Information was also gathered from participants on education, medical history (including history of stroke, myocardial infarction and cancer), alcohol consumption, physical activity, smoking status, height and weight.

Here are 10 things that you may find interesting about this study:

1) I’m a member!

At least I assume I’m a member. I was approached in the 1990s when I was a member of the Vegetarian Society. The Society had been approached to get many vegetarians on board. That would make the UK arm non-reflective of the general population, but it would give a more significant vegetarian population against which to compare. The reason I express any doubt that I’m part of the survey (because I still get follow-up questionnaires) is that I am female but I was not aged 35 or over at any point in the 90′s!

Here’s an example of the questionnaire that I filled in back in the 90′s and I’m pretty sure I’ve had two since – one in the last couple of years. Notice the meat entries on page 3. We were simply asked how often we had each meat (medium serving – whatever that is): never/less than once a month; 1-3 times a month; up to 6+ times a day. You will notice from the journal article that the meat consumption is listed extremely specifically – 0-9.9 g/day; 10-19.9 g/day and so on. How does this general frequency of consumption become such specific intake?

I was a vegetarian at the baseline point of the study (which is the reference point for this article). I have not been a vegetarian for three years. So, if I die now of a heart attack, I am classified as a vegetarian death. Had I been the biggest processed meat consumer in the world in the 1990s and then saw the error of my ways the day after filling in the survey, my heart attack would be attributed to my meat consumption.  That’s how these long term epidemiological studies work.

2) Deaths cannot be prevented – we are all going to die

Ha ha. This one always makes me laugh.

Every study that tries to claim this nonsense should try to estimate by how long they think life might possibly be extended if you do something – in this case, eat less than 160 g/day of processed meat. Dr Malcolm Kendrick did the maths the right way round in the brilliant The Great Cholesterol Con and reduced the headline of “50,000 lives will be saved” to – if 10 million people, at very high risk of heart disease, took a statin for thirty years, aside from any dreadful effects they may suffer along the way, they might extend life expectancy by a couple of months.”

3) When the researcher said that the meat/processed meat eaters were less healthy overall, they weren’t kidding!

Table 1 in the paper gives the baseline information for people in the lowest and highest categories of meat/processed meat/poultry consumption. Page 4 of the study says: “Men and women in the top categories of red or processed meat intake in general consumed fewer fruits and vegetables than those with low intake. They were more likely to be current smokers and less likely to have a university degree”. (We know that there is a link between education level and health and longevity). They went on to say: “Men with high red meat consumption consumed more alcohol than men with a low consumption.”

That’s one way of putting it – in fact, for men, alcohol intake wasn’t just higher – it was up to three times higher in the highest meat intake group than the lowest intake. For men, again, smoking wasn’t just higher – it was up to three times higher in the highest meat intake group than the lowest intake. Table 1 also shows that:

- Men in the highest intake group of red meat were an average 6.4 years older than those in the lowest intake group (age causes death).

- Men in the highest intake group of red meat/processed meat and poultry consumption had higher BMI’s than the lowest intake group.

- Women were also heavier in every highest intake group vs lowest. Almost twice as many women, who were in the highest processed meat intake group, were current smokers.

- The calorie intake differences were striking. Men and women in the highest category of meat and processed meat consumption consumed one and a half times the calories of their counterparts in the lowest categories of meat and processed meat consumption.

So there were a number of big differences between the groups at baseline.

The researchers should have separated Paleo dudes from Pie monsters. Those who eat red meat, vegetables, fish, nuts and seeds are a world apart from those who eat pies, pasties and Peperami pizza!

Table 2 claims that adjustments have been made to Table 1′s data for age, gender, education, weight, height, energy intake, alcohol, physical activity, smoking – everything. I have to assume that this has been done although some of the differentials (three times) will take some ‘ironing out’.

4) The death rates are nothing to lose sleep over

Assuming that Table 2 is accurately reflecting meat consumption alone – there is one interesting observation to be made straight away. In every case (men and women, red meat, processed meat and/or poultry), it is better to consume some meat than none. The lowest intake group is not the best for mortality in any circumstance.

Table 2 has the figure that made the headlines – the “44% greater risk”. Page 4 notes: “Participants with an intake of 160+ g red meat/day had a hazard ratio (HR)  of 1.37 compared with individuals with an intake of 10-19.9 g/day.” When the other factors were taken into account, the HR became 1.14. “The association for processed meat was stronger than for red meat. In the multivariate model [i.e. after allowing for other factors], the HR for high (160 g/day) versus low intake was 1.44.”

Table 2 also shows that (as the abstract confirmed) there is no association between poultry consumption and all-cause mortality in either direction. No positive or inverse association – there’s just no relationship. I will ignore poultry from now on, therefore (with just one wee mention to follow).

Let’s have a look at the death rates in my own little table to summarise numbers all over the paper:

(* The death rate per annum takes the average – median – follow-up of 12.7 years to calculate the death rate in any one year during the study). The relevance of the 1.38 ‘risk factor’ will become clear with the next point.

The first thing to note is that men have twice the death rate of women.

The second thing to note is that the overall death rate is 0.46% in any one year. That’s 4.6 people in 1,000. And those people were aged 40-70 at baseline (men) and 35-70 at baseline (women) making them between 47-48 and 82-83 at median follow-up. If fewer than 5 in 1,000 of that age group were dying each year, I’m not going to worry.

The deaths for different causes were not broken down by gender. Taking them at the top level, the cardiovascular disease (CVD) death rate was 0.1% i.e. 1 in 1,000 each year and the cancer death rate (that’s the health topic that EPIC is all about) was 0.17% i.e. 1.7 in 1,000 each year (17 in 10,000). I’m really not losing sleep over those numbers.

All this nonsense that we hear “One in three people die of heart disease!” “One in three people die of cancer!” Of the people who died in this 12-13 year study, 5,556 out of 26,344 deaths were from CVD – that’s 21% – one in five. 9,861 out of 26,344 were from cancer – that’s 37% – that’s more like one in three. But it’s one in three deaths reported. Not one in three people. If you have two friends, it’s not the case that one of the three of you is going to die over the next year. You need 1,000 friends (aged between 35 and 83) to lose 1-2 of them over the next year.

Those “one in three” headlines are to make sure that you give money to heart and cancer charities. They are not fair and honest numbers.

5) The researchers cooked the books – part 1

Let’s look in more detail at Table 2 – it is fascinating…

The following extract looks at red meat and processed meat only (poultry shows nothing other than you should eat some rather than none). It takes the column claiming that all other factors have been accounted for (called HR (c) – hazard ratio (c)). It shows us where the 1.44 number comes from:

The number of cases (col 1) is in Table 2 and the Hazard ratios (col 2) are in Table 2. So columns 1 and 2 in the table above come directly from Table 2 in the paper. I have added in columns 3, 4 and 5.

Watch what they’ve done with the baseline (1.0). This has been taken as the second lowest meat intake group in all cases. Hence hazard ratios have not been calculated with reference to up to 9 g/day. They have been calculated relative to 10-19.9 g/day in the case of red and processed meat (and 5-9.9 g/day in the case of poultry).

My column 3 gives the hazard ratios had the lowest intake of meat been taken as the baseline (1.0) and not the second lowest – as suited the ‘researchers’.

- For red meat this means that every level of intake is better than the lowest level other than the highest level. i.e. any red meat consumption between 10 and 160 g/day is better than less than 10 g/day and >160 g/day. The single ‘best’ level of red meat consumption (the lowest HR) is 40-79.9 g/day.

- For processed meat, the 1.44 HR headline number would have been 1.38 if the true lowest intake were used as the baseline. The two categories covered by 10-39.9 g/day are better than the lowest intake. Only the 160+ g/day stands out as different. Which brings us to…

6) The researchers cooked the books – part 2

Check out columns 4 and 5 in my table above. Normally, studies like this put consumption into quartiles or quintiles. As an example, where a study divides the groups into quintiles, the researchers take the lowest fifth consumption of red meat and then the next lowest and then the middle of the five groups then the second highest and then the highest. This study has not done this. They have grouped the intakes unevenly with the following outcomes:

- For red meat, 98.6% of deaths are covered by the five lowest consumption groups. Only 1.37% of deaths occur in the 160 g/day group.

- For processed meat, 99.15% of deaths are covered by the five lowest consumption groups. Only 0.85% of deaths occur in the 160 g/day group.

This tells us a number of things:

i)  The study groupings have been manipulated to present a result (I don’t see how else I can phrase this).

ii) The headline could (should?) have been “Not even 1% of deaths, over 12.7 years, occur among those who eat over 160 g processed meat per day”!

iii) 70% of deaths are occurring in the bottom three groups out of six of processed meat intake.  30% of the deaths are occurring in the top three intake groups. (i.e. you’re ‘better off’ in the upper half of consumption than lower half).

iv) Only the top (engineered group) intake of processed meat consumption shows an association worth looking at further and this accounts for fewer than 1% of the total deaths in 12.7 years.

This is like doing a survey about alcoholism and mortality and making the top group so small that it includes Billie Holiday and George Best and making headlines on this basis.

It’s bad science!

7) Other headlines could/should have been

- “Men are twice as likely to die as women!”

- “EPIC study shows you’ve got a one in a thousand chance of dying from heart disease.”

- “Whatever you do, eat meat. Between 10-160 g/day of red meat or your death rate goes up!”

- “70% of deaths in a 12-13 year study were in the lowest half of intake groups of processed meat consumers.”

- “Lies, damned lies and statistics: Researchers cherry pick a baseline to secure global headlines.”

- “Researchers can’t show a relationship between processed meat and death rates in 99.15% of their data, but they still base the headlines on 0.85%”

- “Bloggers are fed up having to waste time analysing nonsense manipulated by people with an end in mind.”

8) It always has to be said – association is not causation

Don’t forget, every study like this can only ever make allegations of association, not causation. There is no association between poultry and death rates or red meat and death rates. Credit where it’s due – at least this was possibly the first study to distinguish between red meat and processed meat – even though the media slipped into interchangeable language almost immediately.

When the correct baseline is taken into account only the top two processed meat intake groups need looking at further. If the consumption had been fairly allocated to quintiles then we would probably have nothing to look at (they didn’t isolate 0.85% of the data for nothing.)

IF any association is left at the end of all the manipulation, it’s still only association. No causation has been proven and there are far more obvious associations for me than the one being implied (processed meat and deaths).

i) People who eat processed meat eat processed food generally, so they are unhealthier all round (as all the cofactors confirmed); and ii) Processed meat comes in pies, pastries, bacon sarnies, covered with brown sauce/tomato sauce etc. The obvious relationship is that the pastry/flour/sugar that accompanies processed and not real meat is the intake causing harm.

The EPIC study has data for all food intake – why do they keep picking on meat? Why don’t they review the association between pies, pasties, bread, pastries etc and deaths or sugar and deaths or processed food and deaths? They are obsessed with demonizing meat to the point of missing the search for stronger and more important health connections.

9) It needs to be reiterated – absolute risk, not relative risk, is what matters

These studies always present relative risk and not absolute risk. The report claimed that those eating more than 160g of processed meat a day (don’t forget the bread and sauce) – were 44% (try 38%) more likely to die over a typical follow-up time of 12.7 years than those eating about 20g (note their careful use of language to exclude the up to 20 g/day group).

As I’ve shown in this post, the overall chance of dying in any one year was 0.46%. This is 4.6 people in 1,000. Even if any meat consumption could be proven as a risk factor (i.e. causation, not association and causation due to processed meat and not the pies and bread that processed meat comes in), the people in the highest intake group (accounting for not even 1% of the deaths) would have a death rate of 6.3-6.7 (38 vs 44%)  people in 1,000. Hardly hold the front page now!

10) And finally…

Lest we forget that this EPIC study is all about cancer and that it has been trying to prove the importance of fruit and veg consumption since its inception, I have to share the comment on page 3 of the article: “Additionally adjusting for fruit and vegetable consumption did not appreciably change the observed associations and was not included in the main models.” i.e. fruit and veg consumption made no difference to the numbers.

The EPIC study discovered this in 2010 – fruit and veg intake makes no difference to mortality – as I have blogged on here. So much for 5-a-day.

Let’s get some definitions out of the way first. Salt can be unrefined or refined. Unrefined salt is also known as sea salt. Unrefined (sea) salt comes with many valuable minerals and natural elements. Refined salt is also known as table salt. This is made up of sodium and chloride. There are approximately 2.4g of sodium in 6g salt. This means that approximately 40% of salt is sodium. You’ll see sodium on food labels, rather than salt.

Here are 10 things that you may find interesting about salt…

1) Like every other government target, the salt dictat has no evidence base

The NHS wants us to eat “no more than 6g salt per day.” (Ref 1) (which equates to 2,400mg sodium). Why? I have no idea and nor does the NHS. Why not 7? Why not 5? Why have a target at all? Goodness only knows. Just like 5-a-day, 14/21 alcohol units, 20-30g saturated fat, 18g fibre – none of these precise targets has precise evidence.

The NHS web site is supposed to provide evidence for government policy. Here is “Salt – the facts” which opens with “Many of us in the UK eat too much salt. Too much salt can raise your blood pressure, which puts you at increased risk of health problems such as heart disease and stroke” and then it goes on to tell you how to cut your salt intake. I don’t know about you but I found those ‘facts’ quite underwhelming.

2) We need to consume salt (and potassium) or we die

We die without salt. It’s as simple as that. Unlike cholesterol, which is also utterly life vital, our body doesn’t make salt. The term “essential nutrient” in nutrition mean that it is essential that we consume the nutrient. Salt is thus an essential nutrient. Fortunately it is in the majority of real foods, including water, and so ingestion of this vital mineral is not difficult.

Potassium is another essential dietary mineral. The potassium/sodium balance, is absolutely critical to the overall functioning of every cell in the human body. If salt levels fall too low, a condition called Hyponatremia can develop, which can be fatal. (Ref 2)

3) Salt has nothing to do with obesity

The inclusion of salt in the Academy of Royal Colleges obesity report (Ref 3) was quite bizarre because salt has nothing directly to do with obesity. It has no calories, no macronutrients (no fat, no protein, no carbohydrate) and therefore cannot directly impact obesity.

There may be an indirect argument that salt could encourage people to eat things. However, I would argue that people may desire doughnuts or biscuits (combinations of flour, sugar and salt), but that they would be unlikely to crave, say, anchovies, unless salt deficient for some reason. I would then expect a salt-deprived person to stop consuming anchovies once any salt deficiency were corrected and not to binge on them. The ‘but for’ test therefore points to the refined carbohydrates, containing salt, being substances of desire and not salt per se.

4) CASH has it in for salt

A charity called Consensus Action on Salt and Health (CASH) exists purely to campaign against salt. As the web site says: “CASH was set up in 1996 as a response to the refusal of the Chief Medical Officer (CMO) to endorse the COMA recommendations to reduce salt intake.” (COMA stands for Committee On Medical Aspects of Food Policy).

The COMA report merely says (and I quote) “The panel recommends that the dietary intake of common salt should not be increased further and that consideration should be given to ways and means of decreasing it.”

The worst thing that the COMA report could say about salt was: “High salt intakes have frequently been linked with the prevalence of high blood pressure in communities but a mechanism whereby salt could lead to the development of essential hypertension has not been established.”

Hang on a second – so there are alleged “frequent links”, for which no evidence is presented and we don’t even know how salt could impact hypertension (high blood pressure)… (I’ll answer this for them in a minute – we’ve known how since Carl Von Voit’s work in 1860).

The COMA report continues “Cross-cultural studies show a statistical association between estimates of salt intake and the average blood pressure of a community but detailed investigations within a single community frequently fail to demonstrate such a relationship.” And CASH was set up because the CMO failed to take action against salt?!

5) ‘High’ blood pressure is in fact normal

If you look at figures 1 and 2 in this highly referenced article, the actual population normal/average blood pressure is 140/86. The European Society of Hypertension and the World Health Organisation both define blood pressure of 140/90 as the baseline for high blood pressure. So normal has been redefined as high. This enables drug companies to medicate many more people.

6) Salt can increase blood pressure, but so what?

There is a very simple mechanism by which salt can increase blood pressure (of which the COMA report didn’t seem to be aware). Salt provides sodium. The normal concentration of sodium in blood plasma is 136-145mM (mmol/Litre). One of the easiest ways for the body to maintain the concentration of sodium is to increase fluid levels if sodium rises. If we consume salty food, we want to drink more (that’s why bars put free bowls of peanuts on the counter) so step 1 is for the increased intake of sodium to lead to an increase in fluid intake. Step 2 means that the additional fluid is more likely to be retained because the body is back in sodium concentration equilibrium, albeit with more sodium and more water.

Water retention in the human body can raise blood pressure. However, there are three points to make here:

i) Raised blood pressure is a symptom. It’s not a problem per se. What the salt antagonists fail to provide is any evidence for a substantial and/or sustained increase in blood pressure as a direct result of any defined level of salt consumption.

ii) Salt opponents also fail to provide any direct causation between salt consumption and end point disease (e.g. heart disease) regardless of whether or not salt impacts blood pressure.

iii) A completely overlooked point is that any rise in water retention from consuming even a couple of grams of salt is incomparable to the impact of consuming 100g of carbohydrates – which we are encouraged to consume (a few times a day) in illogical parallel with the discouragement of salt intake.

We can store up to 500g of glycogen if we consume carbohydrates that are not used up for energy. We know that each gram of glycogen is accompanied by four grams of water. Hence we can gain 2.5kg (c. 5lb) overnight by consuming carbohydrates above human need. This is way more significant in terms of water retention and blood pressure than any impact of a couple of grams of salt – and yet carb consumption is recommended and salt consumption is demonised. Yet another example of our completely incomprehensible dietary advice.

7) Even if salt impacts blood pressure, and even if this matters, reducing salt intake substantially would have negligible impact

The 1994 COMA report (Ref 4) states: “Its [The review group] recommendation was to reduce salt consumption by an average of 3g/day. It has been estimated that this would reduce average systolic blood pressure by about 3.5mm Hg.” [systolic blood pressure is the first of the two numbers we get].

Gary Taubes noted the same in The Diet Delusion: “cutting our average salt intake in half, for instance, which is difficult to accomplish in the real world – will drop blood pressure by perhaps 4 to 5 mm Hg in hypertensives and 2 mm Hg in the rest of us.”

So, halve your salt intake and your blood pressure may go from 130/X to 127/X?

If you have ever had your blood pressure read frequently (while in hospital or getting ready for an operation or a baby), or if you have one of those blood pressure machines at home, you will know that you hardly ever get the same reading twice in a row. Even within a couple of minutes, your blood pressure can vary by more than a handful of points – more than the amount it could possibly change by if you managed to halve your salt intake.

8) CASH’s evidence on “Salt & Health” is completely lacking

For the seven years after its formation, Consensus Action on Salt & Health was relying upon the 1994 COMA report. Since 2003 they have relied upon a Scientific Advisory Committee on Nutrition (SACN) report, called “Salt and Health”. (Ref 5)

Feel free to read the 134 page document. The summary will give you the key elements. The summary opens by saying: “Increased blood pressure, or hypertension, is the most common outcome that has been associated with high levels of salt intake. Hypertension is a major risk factor in the development of cardiovascular disease. The relative risk of cardiovascular disease increases as blood pressure rises even within what is considered the normal range of blood pressure, indicating that large numbers of people are at risk.”

i.e. the most common (the only?) outcome that salt intake has been associated with is increased blood pressure. If there were any direct association between salt intake and any actual disease, it would have been claimed.

Increased blood pressure in turn is then claimed to be a “major risk factor in the development of cardiovascular disease.” I disagree. High blood pressure (BP) (even when properly defined as actual high BP and not normal BP i.e. 140/86) is a symptom, not a cause. This makes blood pressure a condition observed at the same time as heart disease and not a risk factor. (It is far more likely the opposite direction of causation – heart disease causes high blood pressure – hence the symptom).

Notwithstanding this – the argument against salt still boils down to – we think salt is associated with blood pressure and we think blood pressure causes heart disease. So, by inference, they want us to think that salt causes heart disease.

The jewel in the crown of the anti-salt lobbyists is “The International Study of Salt & Blood Pressure” (Intersalt Co-operative Research Group, 1988). This study collected data on 24-hour urinary sodium excretion and blood pressure of over 10,000 adults in 52 population samples from 32 countries. Associations (note, not causation) were found between sodium excretion and blood pressure readings – until the four populations with very low salt intakes were removed from the analysis and then any statistical significance disappeared. (That latter point about the statistical significance disappearing was the view of the SACN Salt and Health report to give credit for honesty – it wasn’t my playing with numbers that led to this finding.)

Dr David Brownstein’s book Salt your way to health noted the findings from the Intersalt study as follows: “Although there was a slight relationship between blood pressure and sodium excretion in INTERSALT, a ‘smoking gun’ could not be found. This study showed a mild decrease in blood pressure (3-6mmHg systolic and 0-3mmHg diastolic) when there was a dramatic decrease in salt excretion.”

9) There is no evidence that salt causes heart disease; there is evidence that low salt is associated with heart attacks

A study of approximately 3,000 hypertensive subjects (men with high blood pressure) found that there was a 430% increase in myocardial infarction (heart attack) in the group with the lowest salt intake versus the group with the highest salt intake. (Ref 6)  Knowing how vital salt is for human health, this should not be surprising – low-sodium diets have been shown to cause multiple nutrient deficiencies, including nutrients vital for heart health (calcium, magnesium, potassium and B-vitamins). (Ref 7)

The SACN report concluded: “There are insufficient reliable data on long-term effects of salt on cardiovascular disease outcomes to reach clear conclusions.” Quite.

10) Eat real food and never worry about salt

Nature puts sodium in real food – we would be dead if this hadn’t happened. Meat, fish, eggs, dairy products, water etc, all contain sodium. These substances also all contain potassium – the balance is taken care of for us. How clever. The most salty foods (seafood) tend to be found in sunnier climes where a) people need more salt to protect against fluids lost in sweat and b) where potassium rich fruits tend to be found as a counterbalance. Clever again.

Salt is not going to kill us. Lack of salt will kill us frighteningly quickly. We should ideally use sea salt rather than table salt – just to get the added minerals and elements – but table salt is not going to harm us either. Processed food contains a lot of added sodium – that’s not what’s going to harm us. The processed food per se is going to do that. The processed food, with its trans fats, sugars, flour, empty calories, lack of nutrition and addictive combinations of manufactured ingredients, is the source of harm – not any sodium contained within.

So just eat real food and don’t worry about salt.

p.s. The interesting twist to researching salt is that the motive for attacking this substance has not been as obvious as usual. The motive in the anti-fat movement is clear – it gives the ‘food’ industry the green light to make highly lucrative fake low-fat food. The motive in the anti-cholesterol movement is clear – it gives the drug industry the green light to make drugs worth tens of billions of dollars and ‘food’ companies can make spreads and other ‘cholesterol-lowering’ fake foods.

The common bad relationships between the ‘food’ industry and health campaigners can be found in the salt world. Check out p12 of the April 2012 Action on Salt annual report   – the usual suspects from the ‘food’ industry are warmly thanked for their support.

Who gains by demonising salt? The lo-salt company clearly does. The founder of Consensus Action on Salt & Health, Professor Graham MacGregor, has personally done well out of founding the organisation. MacGregor is now chairman of action on salt. MacGregor is also chairman of the Blood Pressure Association. He sits on the board for the World Hypertension League and recently served as President of The British Hypertension Society. MacGregor was awarded 37th place on the Independent on Sunday’s list of people who have made Britain a “much, much better place.” (Ref 9) Salt has given MacGregor’s life purpose – I believe that he believes that salt is a bad thing. I also think that he is wrong.

As a final thought – have you heard of the expressions “salt of the earth” or “worth his/her salt”? We describe someone as the salt of the earth when they are as good and worthy as anyone can be. The word salary comes from the Latin word salarium and has the root sal or salt. In ancient Rome, salary meant the amount of money given to a Roman soldier to buy salt, which was an expensive but essential commodity. This explains the “worth his salt” expression. Our language is telling us the truth, our government is sadly not.

References

1) http://www.nhs.uk/Livewell/Goodfood/Pages/salt.aspx

2) http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001431/

3) http://www.aomrc.org.uk/about-us/news/item/doctors-unite-to-deliver-prescription-for-uk-obesity-epidemic.html

4) http://www.actiononsalt.org.uk/salthealth/Recommendations%20on%20salt/42491.pdf

5) http://www.sacn.gov.uk/pdfs/sacn_salt_final.pdf

6) Alderman “Low urinary sodium is associated with greater risk of myocardial infarction among treated hypertensive men.” Hypertension. 1995

7) Engstrom et al “Nutritional consequences of reducing sodium intake.” Ann. Intern. Med. 1983.

8) http://www.charity-commission.gov.uk/Accounts/Ends18/0001098818_AC_20100430_E_C.PDF

9) http://www.independent.co.uk/news/people/news/the-ios-happy-list-2012–the-100-7661358.html?action=gallery&ino=37

The world headlines were all based on this article in the highly respected New England Medical Journal. The researchers’ own headline was “Primary Prevention of Cardiovascular Disease with a Mediterranean Diet”.

Someone I follow on twitter – Rob Lyons (@robspiked) captured it beautifully when I was having my usual rant about people not knowing what the real Mediterranean diet is. Rob replied: “@zoeharcombe no, that’s the diet Mediterraneans eat. This is the ‘Mediterranean Diet’, a mythological diet invented by US researchers.” How true!

The study

Let’s get the facts on the table first. The study involved 7,447 people. 57% were women. The women were aged 60 to 80 and the men were aged 55 to 80. The Guardian was right that they were at-risk groups, as only people with type 2 diabetes or at least three other “major risk factors” (smoking, obesity, family history of heart disease etc) were included in the study. The Sydney Morning Herald was also right about the first heart attack, as only people with no cardiovascular disease at enrollment were admitted to the study.

The diet

This is where we need Rob in our minds. The real Mediterranean diet is high in meat (if it moves, it is eaten – rabbit, pork, beef, chicken, turkey, game, snails etc); fish; cheese; eggs; cream; vegetables & salads; fruits in season and white grains (white bread, white rice, white pasta). Those who eat more of the real food are slim. Those who eat more of the pasta become “Italian mammas”.

The first reference in the study is thus wrong. It claims “The traditional Mediterranean diet is characterized by a high intake of olive oil, fruit, nuts, vegetables, and cereals; a moderate intake of fish and poultry; a low intake of dairy products, red meat, processed meats, and sweets; and wine in moderation, consumed with meals.”

This is what Americans, who have never been to the Med, fantasise that the Mediterranean diet is. However, the truth is that the French/Italians/Greek etc are eating their body weight in red meat and cheese and “wine in moderation” would have an Italian rolling in the aisles. Here are the top wine drinking countries in the world. The prime Mediterranean countries, France and Italy, are in the top five. But for the staggering consumption of the Vatican City, they would be higher! ;-)

Anyway – allowing for the fact that American researchers don’t know what the real Mediterranean diet is, let’s see what the study diet actually was. The 7,447 people were divided into three groups. The study says that they were randomly assigned so, by luck, they appear to have been fairly equally distributed between groups so that there are no obvious confounding differences where, for example, one group has ended up with more than its share of smokers, older people, obese people etc. For once, we can look at the diet as the primary difference to observe.

Two groups were put on this Fictitious Mediterranean Diet (FMD from now on) and the control group were put on a low-fat diet. The two groups on the FMD were also told to avoid soda drinks, bakery goods, spreads, red and processed meat (apart from the red meat, this is excellent advice). The low-fat diet group was told to have at least three servings a day of bread, pasta, potatoes, rice etc – those nicely fattening products that raise triglyceride levels and damage arteries. The FMD group were told to have oily fish. The low-fat group were told to avoid it.

Group 1 doing the FMD was given additional olive oil and group 2 was given 30g of mixed nuts per person per day. The article details that one litre of extra-virgin olive oil was given to group 1 each week and that they were encouraged to consume 50g or more per day. The nut group were given 15g walnuts, 7.5g hazelnuts and 7.5g almonds daily. That’s at least 440 extra calories with virtually no nutrients for the olive oil group (some vitamin E and K but nothing else). The nut group would get approximately 200 extra calories with far more nutrients. Nuts have virtually every vitamin and mineral – many in good amounts. They have protein (olive oil doesn’t – it’s a pure fat).

The fat content in both oil (100%) and nuts (c. 65%) is huge – way higher than the 7% fat content of sirloin steak or the 4% fat content of pork chops. This was a daft study. Why tell groups to avoid natural fat in real food (meat, dairy, eggs) and to replace it with very high fat interventions? (We’ll see why when we see the funders of the study!)

The results

The objective of the study was to measure “primary end points” defined as a major cardiovascular event – a heart attack, stroke or death.

There were 288 such incidents – 96 in the olive oil group, 83 in the nut group and 109 in the low-fat (current government dietary advice) group.

When the incidents in each group were presented as a percentage of person years (i.e. number of people in each group times the average years of follow-up), the incident rate was 0.81% for the olive oil group; 0.80% for the nut group and 1.12% for the low-fat group. As ever, the headlines are big, the real numbers are small. Barely 1 person in 100, in the highest risk groups for cardiovascular disease, at the worst possible age to have cardiovascular disease, actually had an incident during the 5 year study. For the nut and oil groups it was slightly less than 1 person in 100, for the low-fat group it was slightly more than 1 person in 100.

When the incident rate numbers are weighted so that the control group is 1.00, the oil group is 0.73 and the nut group is 0.72. This is relative risk, not absolute. It’s the oldest trick in the book to play to make numbers seem far more dramatic than they are. This is where the headline nonsense of “30% lower risk” comes from. Plus, we always need to remember that this is association, not causation.

The trial was intended to last 6 years. The researchers stopped at 4.8 years – this is usually positioned as “the differences were just so great that we could not morally continue to disadvantage the control group any longer”. A couple of points on this:

1) look at the graph on p8 of the New England Medical Journal paper. The gap between the intervention and control groups is starting to close at the point the experiment is stopped. I’ve seen this convenient ending of trials before.

2) the disadvantage for the control group is that they are following a low-fat diet – not that they are missing out on nuts and/or olive oil. That’s why the headline of the article should have been: “Low-fat diets are associated with cardiovascular disease” Which the media would have likely reported as: “Low-fat diets cause heart disease”. (Except they wouldn’t because the media just loves a good old eulogy about the Fictitious Mediterranean Diet.)

The bottom line

This could have been a very useful study. It could have been an original study to prove that our current low-fat, high-carb, starchy food, diet advice is doing more harm than good. It was essentially comparing a low-fat diet with a real food diet, but with an unnecessary messing around of natural fat delivery mechanisms (being told to avoid natural fat in meat and dairy and to replace it with unnatural levels of olive oil/nuts). Given the nutrition in nuts vs. olive oil, I was surprised that there was no difference between these two groups. This also reinforces the fact that the difference observed was about the low-fat diet being bad and not olive oil or nuts being good.

So why not just do a straight study comparing real food with its natural fat intact and our fake food/low-fat government dietary advice? Who would fund such a study? The funders of this study included: Hojiblanca and Patrimonio Comunal Olivarero (extra-virgin olive oil); the California Walnut Commission; Borges (almonds) and La Morella Nuts (hazelnuts). In the really, really, small print at the end of the article, we also discover that the author conflicts note: “Dr. Ros serves on the board of ‘his institution’ – the California Walnut Commission”; “Dr. Salas-Salvadó is on the board of and receives grant funding from ‘his institution’ – the International Nut and Dried Fruit Council”; Dr. Lamuela-Raventos receives funding from PepsiCo – their snack division does nuts; and Dr. Serra-Majem reports serving on the boards of the Mediterranean Diet Foundation (I never knew there was such a thing!)

As ever – follow the money and all shall be explained!

The latest guidelines acknowledge the extent of the problem: “If current trends continue in Australia, it is estimated that by 2025, 83% of men and 75% of women aged 20 years or more will be overweight or obese.” (p12) This is also a tacit admission that the 2003 guidelines haven’t helped. So are the 2013 guidelines any better?

I am very familiar with the 2003 Australian Dietary Guidelines, as I analysed them in some detail in my 2010 book The Obesity Epidemic: What caused it? How can we stop it? Let’s look at the revised (2013) guidelines in comparison to the 2003 ones, to see if Australian advisors have come up with anything to change this predicted trajectory of obesity.

The three key guidelines

The dietary guidelines for Australians are set by the National Health and Medical Research Council (NHMRC). Like the USA guidelines, the Australian guidelines have the stated aim of promoting the potential benefits of healthy eating to reduce the risk of diet-related disease and also to improve the community’s health and wellbeing. The Australian government has been providing nutrition advice for more than 75 years. The 2003 document was the third edition of the Dietary Guidelines for Australian Adults. The second edition was published in 1992. The NHMRC has also published Dietary Guidelines for Children and Adolescents and the Dietary Guidelines for Older Australians was published in 1999.

The three main pieces of advice in the 2003 dietary guidelines were:

1)     Enjoy a wide variety of nutritious foods:

-      Eat plenty of vegetables, legumes and fruits;

-      Eat plenty of cereals (including breads, rice, pasta and noodles), preferably whole grain;

-      Include lean meat, fish, poultry and/or alternatives;

-      Include milks, yoghurts, cheeses and/or alternatives. Reduced-fat varieties should be chosen, where possible;

-      Drink plenty of water.

2)     Take care to:

-      Limit saturated fat and moderate total fat intake;

-      Choose foods low in salt;

-      Limit your alcohol intake if you choose to drink;

-      Consume only moderate amounts of sugars and foods containing added sugars.

3)     Prevent weight gain: be physically active and eat according to your energy needs.

The three main pieces of advice in the 2013 dietary guidelines are:

Guideline 1: To achieve and maintain a healthy weight, be physically active and choose amounts of nutritious food and drinks to meet your energy needs.

Guideline 2: Enjoy a wide variety of nutritious foods from these five groups every day:

-      Plenty of vegetables, including different types and colours, and legumes/beans;

-      Fruit;

-      Grain (cereal) foods, mostly wholegrain and/or high cereal fibre varieties, such as breads, cereals, rice, pasta, noodles, polenta, couscous, oats, quinoa and barley;

-      Lean meats and poultry, fish, eggs, tofu, nuts and seeds, and legumes/beans;

-      Milk, yoghurt, cheese and/or their alternatives, mostly reduced fat (reduced fat milks are not suitable for children under the age of 2 years).

And drink plenty of water.

Guideline 3: Limit intake of foods containing saturated fat, added salt, added sugars and alcohol.

a) Limit intake of foods high in saturated fat such as many biscuits, cakes, pastries, pies, processed meats, commercial burgers, pizza, fried foods, potato chips, crisps and other savoury snacks.

b) Limit intake of foods and drinks containing added salt.

c) Limit intake of foods and drinks containing added sugars such as confectionary, sugar-sweetened soft drinks and cordials, fruit drinks, vitamin waters, energy and sports drinks.

d) If you choose to drink alcohol, limit intake. For women who are pregnant, planning a pregnancy or breastfeeding, not drinking alcohol is the safest option.

The order has changed, and the 2013 guidelines are more verbose (I left some detail out), but that’s it. Nothing here will make a difference therefore.

The fundamental error

The 2013 guidelines spell out the fundamental error nicely for us with this extract (p16):

“The estimated Acceptable Macronutrient Distribution Ranges (AMDR) related to reduced risk of chronic disease are:

-      20–35% of total energy intake from fat;

-      45–65% from carbohydrate;

-      15–25% from protein.”

This basic lack of understanding about macronutrients (what we know as carbs, fat and protein) and what humans need in their food, is at the heart of the problem. Both sides of the nutritional debate would agree that protein intake of approximately 15-25% is healthy. The real food side would not worry if it went higher, but only as part of a natural intake of real food. Both sides would agree that unnaturally high levels of protein can be dangerous (they can deplete vitamin A and cause liver damage through excessive demands placed with protein metabolism).

Given that everything must add to 100%, if we agree on protein, the only debate we can have is over fat vs carbohydrate. Real foodies say “eat fat, fear carbs.” Dietary advisors say “eat carbs, fear fat.” Real food tends to be naturally high in fat (meat, fish, eggs, dairy, nuts, seeds, avocados, olives, oils etc). Fake food tends to be naturally high in carb (pasta, bread, cereals, and all wheat derivatives).

When fat was first demonised in the UK in the 1984 nutritional guidelines, it was fascinating to see the rationale positioned as – we don’t know that carbs are good, but we think that fat is bad and people need to eat something, so it needs to be carbs. The exact same rationale was given to me by the Food Standard Agency in 2009 when I wrote to them and asked why they recommended carbs over fat.

A basic understanding of human nutrition needs would confirm that the main part of our calorie need is to service what we call our Basal Metabolic Rate (BMR) – the things that the body needs to do each day, even if we’re lying in bed all day and don’t move (i.e. when we don’t need energy to move).

An average woman, doing exercise 1-3 times a week, needs approximately 2,000 calories a day. Approximately 1,500 of these are for BMR needs – cell repair, fighting infection, building bone density, running the body etc. The macronutrients needed to do these jobs are fat and protein. Carbs, as dietary advisors love to tell us, are for energy. And that’s all they are for. Our average woman needs approximately 500 calories for energy. These can come in the form of fat or carbohydrate (the body will use protein if it has to, but as a last resort). So eating 100% of our intake in the form of fat and protein would meet 100% of our needs. Eating 100% of our intake in the form of carbohydrate would meet 25% of our needs. The remaining 75% of carbohydrate would be surplus to requirements. The body would not be able to use this for BMR and would store the carbohydrate as fat. That’s how we get fat and sick.

The Australian government is telling its citizens to eat 45-65% of their calorie intake in the form of carbohydrate. Ian Thorpe (if he still swims) may be able to use up this kind of energy intake. Your average Australian will not. The Australian government is making its citizens fat and sick with this one piece of advice alone.

Servings of carbohydrate

The amount of carbohydrate specifically recommended in the 2003 guidelines was quite spectacular. Pregnant women, breastfeeding women, women over the age of 60, men over the age of 60 all had individual and specific recommendations. The standard advice for women aged 19-60 (not pregnant or breastfeeding) and men aged 19-60 was as follows:

Sample serves are:

-      Cereals/grains – 1 serving would be 2 slices (60 grams) bread, 1 cup cooked rice, pasta or noodles;

-      Vegetables – 1 serving would be 75 grams cooked vegetables, 1 cup salad vegetables, 1 small potato;

-      Fruit – 1 serving would be 1 medium piece (150 grams) of fruit, 1 cup diced pieces or canned fruit, 1 cup fruit juice;

-      Dairy – 1 serving would be 1 cup (250 millilitres) fresh milk, 2 slices (40 grams) cheese, 1 small carton (200 grams) yoghurt;

-      Lean meat/fish/pulses – 1 serving would be 65-100 grams cooked meat or chicken, 80-120 grams cooked fish fillet, 2 small eggs, 1 cup cooked pulses.

An Australian woman, following this 2003 optimally healthy eating advice, could eat 12 slices of bread, three cups of pasta, five small potatoes, two cups of fruit juice, a cup of cooked beans and two servings of junk food every day. This is a staggering amount and proportion of carbohydrate. If I ate a fraction of that, I would be fat in no time.

P39 of the 2003 NHMRC report actually spelled out how to ensure that Australian citizens consume this evolutionary unprecedented level of carbohydrate:

-     “Consume breads with each meal;

-      Regularly use rice, couscous, pasta or noodles to accompany hot dishes;

-      Eat breakfast cereals daily;

-      Include whole grain cereals as extenders to soups and casseroles;

-      Use oats in crumble toppings on desserts;

-      Choose grain-based snacks such as low-fat cereal bars, muffins and popcorn.”

Strewth! And Aussies wonder why they got fat!

The 2013 guidelines are little changed from these 2003 carbohydrate feast tips. The food groups have changed a little (beans and pulses mainly). The main adult category has been changed from 19-60 year olds to 19-50 year olds. Advice for the over 50s is for slightly fewer servings than the servings recommended for the 19-50 year olds.

-      Cereal and grain servings have been revised to be a minimum of 6 for both men and women aged 19-50, as opposed to the previous ranges of 6-12 for men and 4-9 for women.

-      Vegetable servings are now a minimum of 6 portions for men and 5 for women. Beans and pulses are now part of this vegetable group, however, so someone could have 5-6 portions of baked beans a day and tick the box.

-      Dairy has increased to a minimum of 2.5 servings a day – up from 2 servings a day. Dairy Australia is a partner of the Dieticians Association of Australia. Enough said!

-      Australian advisors have gone nuts for beans and pulses – they appear in both the vegetables category and in the lean meat/fish/pulses category. The servings in this latter group have gone up since the 2003 guidelines from 1 serving for men and women to a minimum of 3 servings for men and 2 for women.

Those minimums are inexplicable. While admitting that the country is heading towards 83% of men and 75% of women being overweight or obese within the next 10-15 years, minimum food intakes are being emphasised.

The Plate

Let’s finally look at the Australian summary diagram for ‘healthy’ eating. The 2003 plate can be seen here.

The 2013 plate is barely different.

The Australian plate was already better than the UK eatbadly plate for the following reasons: a) it had no implied brands – no cornflakes implying Kelloggs, no cola implying Coca-cola, no baked beans implying Heinz etc b) it had no junk segment – the junk is off the plate with the message “Only sometimes and in small amounts” and c) it separates fruit from vegetables, noting the significant difference between the two.

The 2013 Australian plate is clearer (not least just for being pictured head on and not at a 3D angle) and the grains segment seems to have been slightly reduced in favour of the vegetables/pulses segment, but the differences are tiny.

The bottom line is that Australians are still being told to base their meals on starchy foods – the exact substances that we used to know to be fattening. They still are fattening – we were not wrong about carbs. But our unfounded fear of fat has led to advice to eat carbs instead. It is our fear of fat that has made us fat and not fat itself.

Four members of The International Network of Cholesterol Skeptics submitted evidence to the steering group. Mine is here.

Björn Hammarskjöld‘s full submission to the steering group is here. (Bjorn’s blog generally is here.)

Barry Groves submitted evidence countersigned by 14 members of thincs. This submission is here.

Below is Stephanie Seneff‘s full submission to the steering group…

We Need a Sea Change to Solve the Obesity Crisis

Stephanie Seneff, Senior Research Scientist, MIT, Cambridge, MA, USA.

1 Introduction

The obesity epidemic will never be solved until we openly admit that we have made a huge mistake in nutritional advice as a consequence of the widely disseminated message to reduce dietary fat and cholesterol. Until we own up to the fact that cholesterol and fat are not the problem, our population will simply grow fatter and fatter.

A minority opinion that is rapidly gaining momentum is that the problem is too many empty carbohydrates, especially sugars, and, most especially, high fructose corn syrup. Dr. Robert H. Lustig, a U.C. San Francisco Professor of Pediatrics, recently produced a youtube video, “Sugar: The Bitter Truth,” which tells the story very clearly, and his recent appearance on the popular 60 Minutes Show, broadcast by CBS, attests to the growing awareness that his message is valid. He tells essentially the same story that we argued for in a recent paper, “Is the metabolic syndrome caused by a high fructose, and relatively low fat, low cholesterol diet?” that was published in the Archives of Medical Science in 2011. The science behind the problem is clear to experts in metabolism, and, ironically, the core problem is a severe deficiency in cholesterol in the membranes of all the cells of the body.

2 The Underlying Science

Sugar enters cells through special channels within confined regions of the cell membrane called “lipid rafts,” which are highly concentrated in cholesterol. With insufficient cholesterol, muscle cells become impaired in their ability to take up sugar, and, as a consequence, sugar piles up in the blood stream, causing glycation damage to blood proteins. Two critical affected proteins are hemoglobin, which delivers oxygen to the tissues, and apoB, which is found in LDL (the so-called “bad” cholesterol). When LDL’s apoB is gummed up with sugar, it interferes with its ability to deliver its goods to the tissues. These goods include fats, cholesterol, fat-soluble vitamins, and antioxidants. So, too much sugar in the blood results in a feedback loop where cholesterol can’t be effectively delivered to the tissues, so they become unable to take up sugar, and the problem snowballs.

When a person eats a meal that contains a substantial amount of highly processed carbohydrates and sugar, along with very little fat, the result is a sharp sugar spike in the blood stream shortly after the meal. Because the foods are so easily digested, and because digestion is not slowed down with the addition of dietary fats, sugar floods the blood just after a meal, and the insulin response overshoots. The beta cells in the pancreas respond by producing a large amount of insulin, to try to eliminate the sugar before it can do damage to blood proteins. Fructose is especially problematic, and it is dealt with by the liver, which rapidly converts it to glycogen and fats. The meal is digested so quickly that, two hours later, when dietary fats should be entering the blood stream, the body is suddenly starved for fuel, and the liver is forced to release more sugar into the blood, from its glycogen stores.

The excess sugar in the blood prevents LDL from delivering cholesterol to muscle cells, and thus they can no longer effectively utilize glucose as a fuel. The solution that the body adopts is to let the muscle cells consume fat instead of sugar. But fat is in short supply because it has been kept out of the diet. So fat cells try to solve both problems – too much sugar in the blood and too little fuel supply to the muscles – by diligently taking up excess sugar and converting it to fat, storing it as a reserve “silo.” However, fat cells can only release fat when insulin levels in the blood are low, because insulin suppresses fat release.

The fats are trapped inside the fat cells because of the excess insulin. The only time the fat cells can release their stores is in the wee hours of the morning, after the excess insulin has finally become exhausted. Fat cells flood the blood stream with triglycerides at this time, in order to provide a buffered supply of fuel to the cholesterol-deficient muscle cells, to tide them over until the next time insulin levels are sufficiently low that fats can be released. So the blood stream contains an excess of sugar, triglycerides, and LDL, all because the diet is too overloaded with empty carbohydrates and excess dietary sugar, and grossly insufficient in cholesterol and fat. High levels of triglycerides, LDL, and sugar in the blood early in the morning, along with obesity, are characteristic features of the metabolic syndrome.

High fructose corn syrup is especially bad. Fructose is ten times as damaging to blood proteins as glucose. Because of this, the liver aggressively processes fructose and converts it into glycogen and fat. In order to ship out the fat it has produced, the liver needs a good supply of cholesterol, because it is cholesterol in the outer membrane of LDL particles that protects the contents from both oxidative and glycation damage. However, cholesterol is completely missing from the diet, due to the aggressive campaigns against it. Cholesterol synthesis is a difficult process involving at least 25 steps, and the liver is unable to synthesize cholesterol because it is distracted by the task of processing fructose. So the liver releases a poor quality LDL, carrying the fat produced by processing fructose, but even more susceptible than usual to damage by exposure to sugars and oxygen in the blood.

3 Solid Evidence from Weston Price’s Research

Every nutritional expert should be required to read the book, Nutrition and Physical Degeneration, by the dentist Weston Price, who travelled the world during the 1930’s, carefully studying the indigenous diets and comparing the physical health of people who still ate traditional diets with the health of those who were eating large amounts of the flour and sugar being newly imported from Western nations. He visited indigenous peoples in northern Canada, in Greenland, in the mountains of Switzerland, and in islands in the South Pacific, and everywhere he went he found the same pattern: people who ate the indigenous diet were healthy; those who were eating lots of imported sugar and flour were not. He provides compelling evidence that foods that are high in cholesterol – seafood, caviar, eggs, organ meats – were consistently highly treasured in all of the traditional cultures he studied. In many cultures, these foods were especially promoted for young women of childbearing age and pregnant women. These are precisely the foods that we are told to avoid today, and this is the key reason why we are unhealthy. The New York Times columnist, Gary Taubes, has tried very hard to convey the message that dietary carbohydrates are the problem, in his book, Good Calories, Bad Calories. And Barry Groves has put forth the same message in his book, Trick and Treat: How “Healthy Eating” is Making us Ill. All three of these books should be required reading for anyone planning a career in nutrition.

4 Which Fats are Healthy?

Beyond the general incorrect concept that “fats are bad for you,” the more specific question of which fats are especially bad is also incorrectly portrayed by health experts and in the media. Dietary fats can be grouped into three major categories: unsaturated, saturated, and trans fats. We agree wholeheartedly with the concept that trans fats should be eliminated from the diet. They are highly damaging to health, mostly because they are shaped like saturated fats, and therefore the body gets fooled, and mistakes them for saturated fats. However, because they are not saturated, they are susceptible to oxidative damage and cause collateral destruction.

The unsaturated fats that are present in cell membranes are protected from oxidative damage by cholesterol. When cholesterol is insufficient, they are more vulnerable to oxidation. Oxidized fats are highly reactive and can cause a cascade reaction with much collateral damage to cell proteins. Because saturated fats lack double bonds (that’s their definition), they cannot be oxidized; this makes them the healthiest fats.

5 Concrete Steps to be Taken

There are several steps that I would recommend to try to combat the obesity epidemic, outlined below

1. A high-level government official, preferably the prime minister, should make a public statement on a highly-visible occasion admitting that we were wrong to blame saturated fat and cholesterol in the diet on the obesity epidemic, and that, instead, people should focus on reducing dietary sugars and processed foods.
2. The following three books should be required reading for all nutritionists and government personnel involved in the obesity campaign: Good Calories Bad Calories by Gary Taubes, Trick and Treat by Barry Groves, and Nutrition and Physical Degeneration by Weston Price.
3. All cakes, cookies, candies, and carbonated beverages should be taxed.
4. An aggressive ad campaign should be initiated to promote foods containing saturated fat and cholesterol, such as kidney pie, oysters, eggs, bacon, butter and whole milk.
5. High fructose corn syrup and trans fats should be banned from all foods. Carbonated beverages should be banned from public schools.
6. Our children should be educated on the benefits of real unprocessed food and the dangers of fast food.

Further Reading

1. Gary Taubes, Good Calories Bad Calories. Knopf Publishers, September 25, 2007.
2. Barry Groves, Trick and Treat: How “Healthy Eating” is Making us Ill. Hammersmith Press, October 15, 2008.
3. Weston Price, Nutrition and Physical Degeneration, 6th Edition, Keats Publishers, June, 2003.
4. S. Seneff, G. Wainwright, and L. Mascitelli, “Is the metabolic syndrome caused by a high fructose, and relatively low fat, low cholesterol diet?” Archives of Medical Science, Vol. 7, No. 1, pp. 8-20, 2011; DOI: 10.5114/aoms.2011.20598

I made a submission to the steering group – I posted it in full on line on this site yesterday.

The press release and the full report can be found here.

THE 10 KEY RECOMMENDATIONS

The 10 key recommendations from the report, or the campaign as it wants to be called, are as follows – they are grouped into three areas. (These 10 recommendations are verbatim, as they appear in the document).

Action by the healthcare professions

1. Education and training programmes for healthcare professionals: Royal Colleges, Faculties and other professional clinical bodies should promote targeted education and training programmes within the next two years for healthcare professionals in both primary and secondary care to ensure ‘making every contact count’ becomes a reality, particularly for those who have most influence on patient behaviour

2. Weight management services: The departments of health in the four nations should together invest at least £100m in each of the next three financial years to extend and increase provision of weight management services across the country, to mirror the provision of smoking cessation services. This should include both early intervention programmes and, greater provision for severe and complicated obesity, including bariatric surgery. Adjustments could then be made to the Quality and Outcomes Framework, providing incentives for GPs to refer patients to such services

3. Nutritional standards for food in hospitals: Food-based standards in line with those put in place for schools in England in 2006 should be introduced in all UK hospitals in the next 18 months. Commissioners should work with a delivery agent similar to the Children’s Food Trust to put these measures into place

4. Increasing support for new parents: The current expansion of the health visitor workforce in England should be accompanied by ‘skilling up’ the wider early years workforce to deliver basic food preparation skills to new mothers and fathers, and to guide appropriate food choices which will ensure nutritionally balanced meals, encourage breastfeeding and use existing guidance in the Personal Child Health Record as a tool to support this.

The obesogenic environment

5. Nutritional standards in schools: The existing mandatory food- and nutrient-based standards in England should be applied to all schools including free schools and academies. This should be accompanied by a new statutory requirement on all schools to provide food skills, including cooking, and growing – alongside a sound theoretical understanding of the long-term effects of food on health and the environment from the 2014/15 academic year

6. Fast food outlets near schools: Public Health England should, in its first 18 months of operation, undertake an audit of local authority licensing and catering arrangements with the intention of developing formal recommendations on reducing the proximity of fast food outlets to schools, colleges, leisure centres and other places where children gather

7. Junk food advertising: A ban on advertising of foods high in saturated fats, sugar and salt before 9pm, and an agreement from commercial broadcasters that they will not allow these foods to be advertised on internet ‘on-demand’ services

Making the healthy choice the easy choice

8. Sugary drinks tax: For an initial one year, a duty should be piloted on all sugary soft drinks, increasing the price by at least 20%. This would be an experimental measure, looking at price elasticity, substitution effects, and to what extent it impacts upon consumption patterns and producer/retailer responses

9. Food labelling: Major food manufacturers and supermarkets should agree in the next year a unified system of traffic light food labelling (to be based on percentage of calories for men, women, children and adolescents) and visible calorie indicators for restaurants, especially fast food outlets

10. The built environment: Public Health England should provide guidance to Directors of Public Health in working with Local Authorities to encourage active travel and protect or increase green spaces to make the healthy option the easy option. In all four nations, local authority planning decisions should be subject to a mandatory health impact assessment, which would evaluate their potential impact upon the populations’ health.

My response

I was due to be on BBC Radio Wales at 6.05am this morning to talk about the report, but the BBC went out on strike at midnight, so it will likely be rescheduled for tomorrow. My points on the campaign are as follows:

*      This was a great initiative – the Academy of Medical Royal Colleges represents the views of the majority of the UK’s 220,000 practising doctors – this was an incredible opportunity to make a significant difference to the biggest public health crisis that humans have ever faced. It has tragically failed.

*      Professor Terence Stephenson, the chair of the steering group, says in the opening remarks “There is no single simple solution – if there was we wouldn’t be in the position we are now.” I disagree. We just need to go back to eating what we ate before we created an obesity epidemic. Make no mistake – this crisis is of our making.

*      The report describes this epidemic in the Executive Summary as “It is a problem that has crept up on us…” I disagree. Obesity increased almost 10 fold in the UK in the three decades following the change in public health dietary advice. This did not ‘creep up on us’. We made it happen and we need to admit that we were wrong and return our dietary advice back to what it was.

*      The major cause of the obesity epidemic is our public health dietary advice. The introduction (1977 USA, 1983 UK) of advice telling us to “base our meals on starchy foods” (foods that we previously held to be uniquely fattening) has made us fat and sick. The majority of the 10 key recommendations are about extending and reinforcing current dietary advice and increasing the army of dietary advisors to give this advice – this will only make the situation worse.

We need  to admit that our current dietary advice is wrong. That the government ‘eatwell’ plate is a shocking diagram – the antithesis of healthy eating.

The idea of a campaign to extend these ‘nutritional standards’ into schools and hospitals horrifies me. It will make matters worse, not better. We need to completely change our dietary advice before telling one more person about it. Every dietician needs to be retrained and to go forth with evidence based advice alone (which excludes “five-a-day”, “carbs are good” and “fat is bad” – none of which are evidence based).

*      Three recommendations are along the right lines, but still wrong:

-      6. Fast food outlets near schools: It’s a good idea to make sure that children have minimal access to junk. However, school dinners, based as they are on nutritionally poor and fattening carbohydrates (pasta, pizza, potatoes etc) are no different to what children can get outside the school gate. Here’s a sample menu - this was just the one at the top of the google search – I didn’t have to look for a particularly bad example. You can probably find your own local authority’s menu on line – they seem to be proud of serving pizza, pasta, chips, ketchup, chocolate brownies, ice cream, cake, jelly and other junk to our next obese generation.

-      7. Junk food advertising: This is the right idea, but the report names the wrong foods – saturated fat, salt and sugar.  This shows that the Academy of Medical Royal Colleges is ignorant about the basics of nutrition…

Saturated fat is a natural component of the most nutrient dense real foods on the planet (meat, fish, eggs, dairy products, nuts, seeds, olive oil, avocados etc). We cannot eat or avoid saturated fat alone. Every food that contains saturated fat also contains monounsaturated and polyunsaturated fats. There are no exceptions. Saturated fat should not be targeted in any circumstances. One of the 15 steering group members, Professor Mike Lean, has a nice little side line doing low-fat pizza - gotta keep fat in jail eh?

Salt is irrelevant to obesity. It is another natural component of real food. Water contains sodium – should we tax water?!

The standard trilogy of saturated fat, salt and sugar is ignorant. The three occur together 15 times in the report – this is like putting Luke Skywalker, Yoda and Darth Vader together. Only sugar is an issue. Any product containing sugar should be banned or taxed out of the reach of most consumers.

-      8. Sugary drinks tax: Right tax, but with three caveats:

a)    This is not new – Sustain called for a 20p per litre tax on sugary drinks on 29th January 2013. Kelly Brownell called for them back in 2009.

b)    Any call for a sugar tax needs to include sweeteners, or the ‘food’ industry will just replace one bad thing with another.

c)     The tax needs to be much higher than 20% to have any effect. A study in the British Journal of Nutrition, March 2011, suggested that a 10% tax on sugared drinks would possibly decrease consumption by 7.5ml per person per day. That’s barely a sip. I would at least double the price of any product containing sugar OR sweetener.

Lest we forget, the British Dietetic Association were one of the 60 supporters of the Sustain campaign for a sugary drinks tax. They have a can of cola on their plate of role model healthy eating – yes – that eatbadly plate!

It is so tragic that the doctors of the UK have missed this opportunity to make a difference. Nothing in this report will halt, let alone reverse, the obesity epidemic and a number of the measures will actually make things worse.

Also, we didn’t need a 60 page report – we just needed the medical profession to come out with those three little words – Eat Real Food!

The first reaction to the campaign

From the 10 recommendations, the BBC led on the call for a fizzy drinks tax. The call for foods high in “fat, sugar or salt” to be relegated to after the 9pm watershed also got a mention, as did the fact that recommendation 2 calls for extra money for weight loss surgery (don’t get me started on that one!) The bariatric surgeons on the steering group, Professor Mike Larvin and Mr Vivek Chitre, wouldn’t have minded the call for £300 million over the next three years for surgery. Dr Rachel Pryke, another member of the steering group, has written to the BMJ in the past expressing her concern over the lack of access to barbaric surgery.

The print media (Guardian, Times, Daily Mail) have similarly led on the fizzy drinks tax.

However, if you watch the BBC report, you’ll see the biggest problem of all – the government has responded to the initiative already by saying its focus is on working with the ‘food’ industry to get companies to voluntarily reduce the calorie content of their food.

As Dilbert used to say “we are doomed!”

Below is my full submission to the steering group…

The Obesity Epidemic

 “The previous nutritional advice in the UK to limit the intake of all carbohydrates as a means of weight control now runs counter to current thinking and contrary to the present proposals for a nutrition education policy for the population as a whole… The problem then becomes one of achieving both a reduction in fat intake to 30% of total energy and a fall in saturated fatty acid intake to 10%.”[i]

Proposals for nutritional guidelines for Health Education in Britain (1983)

And so started the obesity epidemic…

In a study of formerly obese people, researchers at the University of Florida found that virtually all said that they would rather be blind, deaf or have a leg amputated than be obese again.[ii] That is the extent of our desire to be slim and yet two thirds of people in the UK, USA and Australia are overweight and one quarter obese. Why?

To be slim, to achieve the thing we want more than our sight, hearing, or mobility, we are told that we just need to “eat less and/or do more.” Quite specifically, the advice is “One pound of fat contains 3,500 calories, so to lose 1lb a week you need a deficit of 500 calories a day.”[iii]

So, why don’t we follow the advice? Why do we have an obesity problem, let alone an epidemic, when we so desperately want to be slim?

I set out to answer that question in the late 1980’s and this submission is a summary of my findings. In 1972, World Health Organisation statistics recorded 2.7% of UK men and women as obese. Fewer than three decades later, in 1999, the same statistics found 22.6% of men and 25.8% of women were obese.[iv] Two thirds of UK citizens are now overweight or obese.

The USA started from a slightly higher base and displayed a virtually identical trend, with 70% of Americans currently overweight or obese.

The starting point for understanding the obesity epidemic must be: what changed in the late 1970’s/early 1980’s? Was there one occurrence that could explain the sudden and dramatic increase in obesity?

Yes there was. In 1977 the USA changed its public health diet advice. In 1983 the UK followed suit. A more accurate description would be that we did a U-turn in our diet advice from “Farinaceous and vegetable foods are fattening, and saccharine matters are especially so”[v] to “base your meals on starchy foods”. Obesity has increased up to ten fold since – coincidence or cause?

We changed our advice for the wrong reason. We changed it to the wrong advice.

In the 1970’s, the fact that (fewer than six) people (in one thousand) were dying from heart disease was of great concern to America. American public health advisors wanted a solution. Ancel Keys had spent the 1950’s trying to prove that cholesterol consumption was the cause of heart disease. He failed and he acknowledged this. He then tried to prove that saturated fat consumption causes heart disease, despite this having no logic, not least because saturated fat and cholesterol (and unsaturated fat) are found in the same foods. At the time that Senator McGovern was looking for the first Dietary Goals for the United States, the Keys theory was not the only idea available for consideration, but it was the best promoted. The rest, as they say, is history.

The USA changed its dietary advice and the UK followed. We told people that fat was bad and carbohydrate was good not because we knew either fat to be bad or carbohydrate to be good. At the time we changed our advice, the only ‘evidence’ for fat being bad was a suggestion that, in seven handpicked countries, heart disease tended to be related to cholesterol levels, which tended to be related to saturated fat intake and so (that must mean) heart disease tended to be related to saturated fat, (although cholesterol intake was not directly related per se). Association was never proven and causation was never alleged. We had no evidence that carbohydrate was good – just the admission that, if we tell people not to eat fat they must eat something and “it was advised that starchy carbohydrates should replace the reduction in fat as an energy source.”[vi]

We have not looked for proof since:

-    “There has been no controlled clinical trial of the effect of decreasing dietary intake of saturated fatty acids on the incidence of coronary heart disease nor is it likely that such a trial will be undertaken.” (COMA, 1984).[vii]

-    “It has been accepted by experienced coronary disease researchers that the perfect controlled dietary trial for prevention of coronary heart disease has not yet been done and we are unlikely ever to see it done.” (Truswell, 1994).[viii]

-    “The ideal controlled dietary trial for prevention of heart disease has not yet been done and it is unlikely ever to be done.” (FSA, 2009).[ix]

The ultimate irony is that if Keys did show anything, he showed a relationship between the 100% carbohydrate, sucrose, and heart disease: “The fact that the incidence of coronary heart disease was significantly correlated with the average percentage of calories from sucrose in the diets is explained by the inter correlation of sucrose with saturated fat.”[x] Decades later we have not corrected this fundamental mistake and we still list biscuits, cakes and pastries – carbohydrates first and invariably unsaturated fat second – as saturated fats. We changed our advice to try to alleviate heart disease and, as a result of this catastrophic confusion over macronutrients, our citizens are consuming more of the foods that should have been clearly identified as the culprits in the first place.

We have forgotten that we eat for nourishment. We have a vital need for nutrition and we have lost this basic value in our current dietary advice. If we had stayed true to the principle of why we eat, the most nutritious foods would be evidential in any analysis of fat, protein, vitamins and minerals. They are the liver, sardines, milk, eggs and greens favoured by our elders and not the fortified cereals and margarines favoured by conglomerates and, reprehensibly, far too many dietary advisors alongside.

An industry originated marketing campaign, five-a-day, has become the leading public health message in tens of countries across three continents and it is spoken of as if there is overwhelming evidence behind it, when the reality is that there is none. Worse, if the proponents of pick-a-number-a-day knew what Dr Richard Johnson[xi] and Dr Robert Lustig[xii] know, they would surely revise their opinion of fructose and never mention fruit juice again.

We have slandered and libelled the most nutritious macronutrient – fat and we have promoted and praised the least nutritious macronutrient – carbohydrate. We don’t need to look far to understand why. The most nutritious foods on the planet are those provided by nature, naturally rich in protein and fat. The most profitable foods on the planet are those provided by food manufacturers, UNnaturally abundant in sugar, flour and vegetable oils.

As the demonisation of real food has gathered pace, fledgling and long standing food and drink companies have become multi-billion dollar empires. “The world’s largest convenient food and beverage company”, PepsiCo, is bigger than 60% of the countries in the world.[xiii] An immense and profitable industry has grown on the back of the low fat, high carbohydrate advice that we invented. Human beings have become high fat and low health in parallel.

When people talk about “the obesogenic environment”, they do so as if this were some inexplicable phenomenon that crept up on the world and made everyone fat. We created this obesogenic environment; it did not happen to us. We told people to avoid real food and to eat processed food. We passed legislation to introduce trans fats and sweeteners into our food chain. We allowed our children to be given toys, cartoon characters and junk food by ‘strangers’.[xiv] We have facilitated the comprehensive infiltration of the food and drink industry into our dietary advice – nowhere more so than in the fattest nation on earth, America, where we have gone as far as legislating the relationship, so that only the food industry sponsored American Dietetic Association can advise the unsuspecting public. We put cakes, cola and sweets on government posters, pyramids and plates of role model healthy eating. We welcomed food and drink industry funds turning global sporting events into advertising arenas for their products. We continue to revere sports and pop stars, who are paid millions of dollars to endorse products that they likely don’t consume themselves. We care more about the profitability of Kellogg’s and McDonald’s than we do the health of our citizens. Prove me wrong governments and take decisive and immediate action. Just don’t act like this environment is nothing to do with you.

Had we changed our advice for the wrong reasons and to the wrong advice without consequence, we would have been fortunate. We have not been fortunate. We have paid an enormous price for this change; with a tenfold increase in obesity. Furthermore, more people are continuing to become obese and the obese are continuing to become more obese and we have not yet had the first generation born to our most obese generation. It is not unreasonable to say that on the back of one man’s study, first adopted by one American Governor and then the world, we have an obesity epidemic.

As obesity doubled for UK adults between 1972 and 1982 and then almost doubled again by 1989 and then almost another time by 1999, the urgency and desperation to lose weight was palpable. The advice that people were given was the same as the advice that made them overweight in the first place: eat less fat – eat more carbohydrate; eat less real food – eat more processed food.

Eat less/do more became such a common mantra that we stopped looking for the real solution to obesity; despite the fact that we had evidence going back to 1917 that eat less/do more does not work.[xv] The level of failure was quantified in 1959 by Stunkard and McLaren-Hume at 98%.[xvi] Another irony could be that we ignored the brilliant and unbiased study done by Ancel Keys and favoured instead the one where he set out to prove an already held view. Keys did the definitive study to show exactly what happens when we manage to restrict calorie intake and that even this can only be achieved ‘in captivity’, due to the hunger that ensues. We know from The Minnesota Starvation experiment that calorie restriction results in a disproportionate reduction in energy expenditure and metabolic activity and that the ‘circular reference’ will defeat the dieter in weeks.[xvii]

As we tried to fix a crisis, without making the connection that we started it, we compounded the challenge by proceeding on the basis of flawed assumptions – theoretical and empirical.

The theoretical error we made was to simplify the application of the laws of the universe to the world of dieting – we got the first law wrong and ignored the second law. If we had considered both properly, we would have realised that obesity is not a simplistic outcome of energy in (overweight people eat too much) and/or energy out (overweight people are too sedentary). We would have realised that energy in can only equal energy out if the body makes no internal adjustment whatsoever. Not only is this biochemically impossible, the internal adjustment made by the body, in response to changes in energy intake and/or energy requirements, is likely far greater than any change in fat reserves that the body can or will make.

Empirically, we got hold of a calorie formula, we know not from where, which we hold to be true and continually prove to be untrue. One pound does not equal 3,500 calories. We will not lose one pound if we create a deficit of 3,500 calories. The most fundamental tenet of the diet world fails basic scrutiny. Worse, seven public and obesity health authorities (Department of Health, NHS, British Dietetic Association, Dieticians in Obesity Management, Association for the Study of Obesity, National Obesity Forum and National Institute for Clinical Excellence) all failed to prove their formula and none knew from whence it came. If we carried on teaching children that London is the capital of America, when we knew this to be wrong, there would be uproar. Yet when the hopes of 1.5 billion overweight people depend upon an equally wrong, but vastly more serious, untruth, we continue to lie.

We know that any answer to the obesity epidemic must explain what has changed since circa 1980. The answer, therefore, can not be found in something we have been eating for over one hundred thousand years (real food – especially fat). The answer can not be found in anything we have been eating less of during the past thirty years (real food – especially fat). The answer can be found in anything we have not been eating for over one hundred thousand years (processed food – especially carbohydrate). The answer can be found in anything we have been eating more of during the past thirty years (processed food – especially carbohydrate).

The answer similarly can not be found in the other half of the energy in equals energy out oversimplification. Sedentary behaviour did not cause the obesity epidemic. Exercise will not cure it. The conclusion of the one study that tried to quantify the contribution played by energy intake vs. energy expenditure (Swinburn) was that Americans had been expending more energy during the period in which the average person gained 20 pounds.[xviii] The Department of Health document At least five a week admits that the evidence for the benefits of exercise for preventing or treating obesity is not in abundance and not strong. [xix]

We opened with Colleen Rand’s brilliant study of how much people would rather be something else than obese. The precise numbers were that 100% of those researched would rather be deaf, 89% would rather be blind and 91% would rather have a leg amputated – than be obese. Proposed solutions are that we surgically impair the stomachs, of our fellow humans. The suggestion that we might return to eating the way that we did, before we needed to invent such drastic procedures, is instead seen as radical.

The decision made by humans to move away from the diet that we have evolved to eat has led to two thirds of the ‘evolved’ world being overweight and a number wishing that they were literally anything else, rather than obese.

As Barry Groves observed: “Man is the only chronically sick animal on the planet.”[xx]

That’s because man is the only species clever enough to make his own food and the only one stupid enough to eat it.

How many more obese humans do we plan to produce before we stop feeding them man-made food? Will the man-made obese ever forgive us for what we have already done? Will we ever forgive ourselves if we make any more? Is it really so preposterous to suggest that we simply return to eating the real food that our planet provides for us? The real food that we used to eat, before we got so fat we’d rather be blind.

Zoë Harcombe

‘Food’ manufacturers have been summoned to crisis talks with Environment Secretary Owen Patterson. Fingers of blame are being pointed from the Food Standards Agency to Poland. Vegans and real foodies are having a field day (excuse the pun). So, what’s the issue?

There are three issues worthy of exploration:

1) The health issue

2) The animal issue

3) The trust issue

1)  The health issue

Let’s start with the health issue. When horsemeat was first discovered in value burgers I tweeted that this would likely be the healthiest part of the product. Burgers can have starch, wheat flour, sugar, preservatives and things that you wouldn’t recognise in them. The meat, albeit rarely the healthiest cuts of the animal, will be the most nutritious part.

What is the nutritional content of horsemeat? Have consumers suffered a detriment by consuming meat from a horse instead of meat from a cow from a nutrient perspective? The table below compares five products. Column 2 has the meat that was supposed to go in the burgers and lasagne – i.e. mince beef. Column 3 has the nutritional analysis of horsemeat in general. I’ve included the most nutritious single food on the planet, liver, as a comparator as well as a piece of fruit (to show how lacking it is compared to meat) and the single ingredient that Brits and Americans consume the most of – the nutritionally poor but omnipresent, white flour.

You can see that the horsemeat scores well when compared to the beef. Lower in calories (if you care about that sort of thing), a higher nutrition score (the United States Department of Agriculture rating of individual foods) and a higher overall protein quality. Beef is better than horse for 4 vitamins, horse is better than beef for 5 vitamins and they are equal for 3. When it comes to minerals, beef is better than horse for 4 minerals, horse is better than beef for 4 vitamins and they are equal for 2. It really is neck and neck (pun alert!)

There have been some concerns that the horsemeat may contain drugs unfit for human consumption. At the time of writing this blog, this has not been determined. This concern aside, comparing nutrients alone tells us that the nutrition provided by the unexpected ingredient (horse) is no worse than that which the consumer expected to get (beef).

2) The animal issue

When it comes to animals and humans, we all draw the line in a different place. At one extreme we have the survival expert, Bear Grylls, who has the line drawn beyond all animals – he would eat any of them to survive. He has even eaten their waste products on television. At the other extreme we have people who will not eat any animal (meat, fish), any products from an animal (dairy, eggs), who will not wear any product from an animal (leather, wool) and will not utilise any product for which animals have been involved in the process (drugs, toiletries etc). As Lierre Keith so beautifully described in The Vegetarian Myth even vegans cannot consume any food for which an animal has not died. From the wolves and bison displaced for grain and soy(a) production, to the slugs destroyed to produce lettuce, to the fish killed as rivers are diverted to irrigate plant foods – we cannot eat anything for which something else has not died – no matter how much we wish to draw our line beyond this fact.

The emotive part of the horsemeat scandal is that many people do not want to eat horsemeat. Brits particularly, have an issue with eating horses – an issue that is not shared by much of the rest of Europe or by parts of Asia. Brits see horses as pets rather than food. A number of people have been deeply offended to discover that they have eaten horsemeat when they would not have chosen to do so. These people draw their line between horse and cow – the latter is OK, the former is not. This brings us on to…

3) The trust issue

The real issue in this scandal has to be about trust. People have trusted ‘food’ manufacturers to put what it says on the packet in the packet. This is not unreasonable, but, dare I suggest, it’s a bit naive? I say this because I wonder if consumers of processed ‘food’ ever know precisely what they’re eating. If you eat processed ‘food’ you may encounter the following ingredients, just as examples: hydrogenated fats; monosodium glutamate; maltodextrin; sodium caseinate; autolyzed yeast; autolyzed vegetable protein; hydrolyzed vegetable protein; citric acid; BHA (Butylated Hydroxyanisole); BHT (Butylated Hydroxytoluene); sodium nitrate; propyl gallate; sodium benzonate; benzoic acid; potassium bromate… Have you ever consumed aspartame? Have you ever Google’d ” dangers of aspartame”?

Give your child glucose syrup, sugar, gelatine (derived from the collagen inside animal skin and bones), dextrose, citric acid, flavourings, fruit and plant concentrates, colours (including carmine, which is made from crushed insects – usually red beetles), glazing agents (including beeswax), invert sugar syrup and fruit extract and no one will bat an eyelid. That’s the ingredients list for (sing along) “Kids and Grown-ups love it so, the happy world of Haribo”. And this is supposed to be a treat?!

British consumers have every right to feel let down by ‘food’ manufacturers. ‘Food’ manufacturers are unworthy of your trust. And, given the other nasties they regularly put in their fake food, they were unworthy of your trust long before horsemeat found its way into their ‘beef’ products. If you consume processed ‘food’, you really have no idea precisely what you are consuming. Why be any more outraged by a nutritious substance like horsemeat and not nutritionally void sugar and the chemical list above?

There is only one way to know precisely what you’re eating and that is to eat real food. This horsemeat scandal has not been an issue for me personally, as I know exactly where the lambs, pigs and cattle that I eat graze. I pass the chickens that deliver my eggs on the dog walk 2-3 times a day. I don’t eat anything that requires a label. If you want to ensure that any future food scandals have nothing to do with you, the strategy is really simple – JUST EAT REAL FOOD!