Friday, 23 July 2021

A swift half with Kristian Niemietz

Here it is! The Swift Half with my friend and colleague, Kristian Niemietz...

Thursday, 22 July 2021

Last Orders with Leo Kearse

There's anew episode of the Last Orders podcast out, with the comedian Leo Kearse. We discuss censorship in comedy, Henry Dimbleby's lust for food taxes and 'Freedom Day'.

A new Swift Half with Snowdon will be coming soon.

Wednesday, 21 July 2021

You can eat a healthy diet for next to nothing. Here’s the proof

First published by Spectator Health in March 2017

It is a common belief in some circles that a healthy diet is unaffordable. Last year, the chair of the Royal College of GPs said fruit and vegetables were so expensive that it was unrealistic to expect people on low incomes to eat their five-a-day. As five-a-day morphs into ten-a-day, the Food Foundation said at the weekend that people on low incomes would find it ‘impossible’ to eat 10 portions of fruit and vegetables. Meanwhile, fast food chains like McDonald’s are blamed for filling our stomachs with ‘cheap junk food’ and there are growing calls for taxes on ‘unhealthy’ food to address the supposed imbalance between expensive good food and inexpensive bad food.

These beliefs have never been supported by much evidence, however. The Food Foundation says that ‘healthy foods are three times more expensive calorie for calorie than unhealthy foods’, but measuring the cost of food by the calorie — as some studies do — tells us nothing about the price of a healthy diet. By this measure, a low-calorie yoghurt would appear more expensive than a high-calorie yoghurt despite both products costing 50p each. You’d obviously need to buy more of the low-calorie yoghurts if you wanted to consume 1,000 calories, but that is not a useful measure in modern Britain where consuming enough calories to survive is not the problem. For most people, the challenge is to consume fewer of them.

The real question, therefore, is whether it is cheaper to live off processed food and takeaways than to eat a nutritious, balanced diet. The government’s Eatwell Guide recommends a diet that is heavy on fruit, vegetables, starchy carbohydrates and white meat. All of these can be bought from supermarkets at prices that would have amazed your grandparents. As I show in a new report from the Institute of Economic Affairs, rice, potatoes and pasta can be bought for less than 5p per serving. Grapes, oranges and bananas cost less than 30p per serving and apples and pears can be bought for less than 10p. An 80 gram serving of carrots, tinned tomatoes, peas or cabbage costs less than 8p.

All told, it is possible to have your five-a-day for less than 30p and a nutritious, if plain, diet can be bought for less than £1 a day. Add some muesli, bread, chicken fillets, fish and jam, and you can have a tastier and more varied diet for less than £2 a day.

Compare that to the cost of ‘junk food’. Chocolate breakfast cereals are twice as expensive as bran flakes or muesli. The cheapest own-brand ready-meals cost at least £1 each. Sugary snacks are almost invariably more expensive than apples or pears. An 80 gram serving of crisps is four times more expensive than an 80 gram portion of banana or broccoli, and sugary drinks are not only more expensive than water but are often more expensive than low-calorie soft drinks such as diet lemonade and sugar-free orange squash.

Furthermore, if you compare the diet version of products to their originals, they are usually the same price or less. Brown bread costs the same as white bread, light baked beans cost the same as standard baked beans, light mayonnaise costs the same as full-fat mayonnaise, skimmed milk costs the same as whole milk, and so on. You cannot blame financial constraints on people’s reluctance to buy them.
And it should go without saying that buying the ingredients for a healthy meal costs less than going to a fast food chain. The cheapest adult meal in McDonald’s costs around £4.50. A single meal for a family of four costs the best part of twenty quid.

This is not to say that a bad diet has to be expensive. If you want to live off frozen pizzas, chips and sausages you can do so for a relative pittance. Food, in general, has never been cheaper. But a diet of stereotypical ‘junk food’ is not cheaper than a healthy diet and is usually more expensive.

Unless you have servants to do your shopping, this probably seems obvious. The theory that Britain has high rates of obesity because healthy food is unaffordable is flawed on every level. It does not explain why obesity has increased while food prices have fallen to historic lows, nor does it explain why obesity rates are higher in rich countries than in poor countries. It does not explain why people fail to buy more fruit and vegetables when they become richer and it does not explain the high rate of obesity among people on middle and high incomes.

Why, then, do so many take the lazy assumption that healthy food is expensive at face value? In part, it is because some health campaigners want to portray obesity as an economically driven phenomenon in order to justify taxes and subsidies on food, but there are other reasons. According to a study in the Journal of Consumer Research, people assume that expensive food products are healthier even when they are not. The mere existence of a price premium seems to imply health benefits to some consumers. Organic and gluten-free food, in particular, are assumed to be healthier as a result of their price and because of the exaggerated claims made on their behalf.

The chef Anthony Warner argues that fad diets and wellness gurus ‘focus almost solely on exclusive, exotic ingredients’ such as quinoa and chia seeds at the expense of ‘cheap, easily consumed sources of valuable nutrition like carrots, potatoes, bread and cheese’. If you assume that ‘healthy’ means organic, imported or gluten-free then you will end up spending more money but there are plenty of unpretentious, nutritious fruits and vegetables available on supermarket shelves for next-to-nothing.
Meanwhile, ‘cheap junk food’ is not so cheap, in relative terms. The appeal of Big Macs, ready meals, frozen pizzas and chocolate fudge cake is not that they are cheap but that they are tasty, convenient and require no cooking skills. These are things that people are prepared to pay a premium for — and they do. Price is not unimportant, but if it was the main determinant of dietary choices, we would all be eating ten-a-day.

Tuesday, 20 July 2021

No global booze taxes, UK tells WHO

The UK government has responded to the World Health Organisation's draft action plan on alcohol. The corrupt and incompetent WHO has shifted the goalposts with its Global Alcohol Strategy. It wants to move away from a target of reducing alcohol-related harm by ten per cent worldwide to reducing alcohol consumption by twenty per cent worldwide. This is not going to happen (it wants to do this by 2030!) and there is no economic or ethical justification for it. 

It also wants member states to raise taxes on alcohol and give the money to the WHO. And it wants a Framework Convention on Alcohol Control modelled on the Framework Convention on Tobacco Control (we tried to warn you this would happen).

The UK, quite rightly, is not having this. In some curt comments at the end of the UK's response (p. 490), HM Treasury tells the WHO where it can stick its FCAC and its global alcohol tax.

HM Treasury (HMT) are carrying out a review of alcohol duty. HMT is not in agreement to a direction of travel that seeks to put alcohol on the same footing as tobacco. Particularly the mooted suggestion of creating a FCTC-equivalent for alcohol, as this would be unviable. 
HMT further commented on the action points in section 6: 
  • Global target 6.1: 50% of countries have increased available resources for reducing the harmful use of alcohol and increasing coverage and quality of prevention and treatment interventions for disorders due to alcohol use and associated health conditions. 
  • Global target 6.2: An increased number of countries with earmarked funding from alcohol tax revenues for reducing the harmful use of alcohol and increasing coverage and quality of prevention and treatment interventions for disorders due to alcohol use and associated health conditions. 
This would not be supported in any way. It’s antithetical to HMT to hypothecate taxes, and we would say that resourcing of alcohol prevention/treatment is a matter for member states in line with their national circumstances and not something to be determined by WHO targets.

That's them told. Maybe the WHO should spend a bit more time working on infectious diseases and a bit less time worrying about what people drink.

Note that the document says that hypothecated taxes as 'antithetical' to the Treasury. Bad news for anyone who believes that the revenues from Henry Dimbleby's proposed sugar and salt taxes would be earmarked for cuddly causes. Remember how campaigners said the revenue from the sugary drink tax would go towards school sports and breakfast clubs? It never happened.

Obesity and physical inactivity - the evidence

First published by the Spectator in 2015

Part One

You may have heard the news that the nation’s doctors have had a change of heart about physical activity and no longer believe it to be a sensible way of staying slim. Don’t be too quick to put your feet up. All is not as it seems.

The doctors responsible (or, arguably, irresponsible) for this claim are Aseem Malhotra, Tim Noakes, and Stephen Phinney. Malhotra is a Croydon-based cardiologist who rose without trace several years ago, first attacking junk food and then climbing aboard the anti-sugar bandwagon. Now the scientific director of the wacky pressure group Action on Sugar, he explicitly tells people to eat more saturated fat and implicitly tells people not to bother exercising – unusual advice from someone who looks after people’s hearts for a living. Last year, he wrote an article for the British Medical Journal which was investigated and corrected after it made insupportable claims about the safety of statins. It turned out that Malhotra had brushed aside concerns raised by one of the peer reviewers. His Action on Sugar briefing papers have also contained very questionable assertions.

Malhotra’s co-author, Tim Noakes, is a South African paleolithic diet advocate currently promoting a new diet book. He disputes the evidence that high cholesterol is a risk factor for heart disease and is currently being investigated by the Health Professions Council of South Africa for ‘disgraceful conduct on social media’ after telling a mother on Twitter to wean her infant on to a low-carb diet. (Noakes appears to be taking this in his stride.) Stephen Phinney, the other co-author, is a scientific advisory board member of Atkins – as in the Atkins Diet – and has written several books extolling the low-carb way of life.

They are not, in short, typical doctors. Together they wrote a short editorial for the niche British Journal of Sports Medicine, in which they made the striking and unambiguous claim that ‘physical activity does not promote weight loss’. They then praised the alleged virtues of fat and called for legislation to clamp down on carbohydrates, especially sugar.

Curiously, the authors’ poorly referenced, 1,000-word opinion piece became a national news story. The op-ed was (wrongly) described as a ‘scientific study’ by the Independent and the trio were (questionably) described as ‘international experts’ by the BBC. Indeed, the Beeb’s claim that ‘Physical activity has little role in tackling obesity – and instead public health messages should squarely focus on unhealthy eating, doctors say’ made it sound as if this was the consensus view of the medical profession rather than the eccentric opinion of three Atkins evangelists, one of whom is a lobbyist for a pressure group.

The idea that burning off calories does not help prevent weight gain is idiosyncratic to say the least, but the media haven’t misrepresented them. That is what they say in their article and there is no reason to think they don’t believe it. Malhotra has previously boasted of having convinced the Minister for Public Health that ‘physical inactivity is not linked to obesity’. Their evidence for this claim seems to boil down to the fact that obesity has risen in recent decades despite levels of physical activity remaining the same. Therefore obesity must have risen because people are eating more calories.

The trouble is, it is not a fact. As Public Health England noted in a major report last year, ‘People in the UK today are 24 per cent less active than in 1961’. British Heart Foundation figures show that British adults are walking less (from 255 miles per year in 1976 to 181 miles in 2012) and the proportion of British children who walk to school has dropped from 70 per cent in 1980 to less than 50 per cent today.

At work, we are less physically active than ever. Jobs in agriculture declined from 11 per cent to two per cent of employment in the 20th century while manufacturing jobs declined from 28 to 14 per cent. Less than one in five adults report doing any moderate or vigorous physical activity at work. Outside of work, 53 per cent of us take part in no sports or exercise at all.

You don’t need to be a social historian to see that Britons are leading increasingly sedentary lifestyles. Only a minority of households owned a car in 1965. Today, only a quarter do not. In Britain, as in all western countries, there have been what the World Health Organisation describes as ‘decreased physical activity levels due to the increasingly sedentary nature of many forms of recreation time, changing modes of transportation, and increasing urbanisation’.

If Malhotra et al’s theory seems counter-intuitive it is for the simple reason that it doesn’t stand up. They provide no new research in their ‘study’ and only cite one article in support of their claim about physical activity. That, too, is an opinion piece from the fringes of the scientific debate and has been widely criticised. The phrase ‘overwhelming evidence’ can be overused, but it can certainly be applied to the countless studies showing that physical activity helps prevent weight gain – and to the data showing that rich westerners burn fewer calories than their grandparents.

Why claim something that can so easily be challenged by reference to laboratory, animal and observational trials? Why fly in the face of empirical evidence and lived experience?

The answer, I think, lies in political pragmatism. Governments are not yet ready to pass laws forcing people to exercise, so it makes sense for the likes of Action on Sugar to focus on the food supply where regulation is more likely. A soda tax is more realistic than a sofa tax. If politicians view obesity as a cultural symptom of greater wealth and structural changes in the labour market, they will be less likely to support taxes, advertising bans, graphic warnings and all the other interventionist policies that you would expect from a campaign group which claims that ‘sugar is the new tobacco’.

This, admittedly, requires a certain amount of self-delusion, since the cold facts show that physical activity is not the only thing that has declined since 1980 – sugar consumption has too. But what are activists to do? Bore people with all of the science? Leave them alone? Of course not. Better to trust the media to be suitably deferential to them on account of their PhDs. The media did not let them down last week. The closest Malhotra came to being challenged was when the National Institute for Clinical Excellence said that an obesity strategy that ignored physical activity would be ‘idiotic’.

The multi-million-pound diet industry is, largely if not wholly, based on the conceit that there is more to weight loss than calories in and calories out. Supposed diet gurus will be ignored by right-thinking people, but the line between these people and the medical establishment is becoming increasingly blurred.

It’s difficult to say which is more depressing – three medics making a highly doubtful claim which, if acted upon, would probably harm people’s health, or the media taking a one-page editorial from an obscure journal and reporting it as news. Since most people don’t take health reporting too seriously, the damage to the public is likely to be negligible. It is more likely to be a blow to the reputation of the ‘public health’ lobby, but given the say-anything, do-anything mentality of some self-styled public health experts, it is a blow that is well deserved.

Part Two

Last week I mentioned a widely reported article in the British Journal of Sports Medicine which claimed that ‘physical activity does not promote weight loss’. The article was taken down by the journal last week due to ‘an expression of concern’. It remains offline as I write this, but the controversy rumbles on. At the risk of further upsetting the low-carb community (who seem particularly antagonistic to the doctrine of ‘calories in, calories out’), I am returning to it today.

Let’s start by looking at a series of blog posts by Jason Fung of Intensive Diet Management that have been doing the rounds on social media. He, too, argues that ‘there is no measurable association between obesity and physical activity’. In his first post, he argues that people are exercising more than ever and yet are becoming fatter and fatter. The positive correlation between obesity and exercise, he says, shows that physical activity really doesn’t make much of a difference.

I once met somebody who wondered whether artificial sweeteners caused obesity, based on the fact that their use had risen more or less in line with obesity rates in recent decades. It seems pretty obvious that this is a case of reverse causation. Artificial sweeteners are a response to obesity, not a cause of obesity, just as the rise of jogging and gym membership is a response, not a cause.

To be fair, Fung is not claiming that exercise causes obesity, only that it is not a solution. He cites figures showing that Brits are exercising more than they used to – or, more precisely (and this is crucial), that more Brits are exercising than they used to. Forty-two per cent of British men met the government’s physical activity recommendations in 2008, up from 32 per cent in 1997. At the same time, the male obesity rate rose from 17 per cent to 24 per cent.

But, leaving aside the question of whether people accurately report how much they exercise, why would we expect the minority who exercise to have an effect on the majority who don’t? There is nothing incongruous about obesity rising even if one in ten men are exercising more than they used to. Moreover, there is a conflation between physical activity and leisure-time exercise that is often made by those who downplay the benefits of physical activity.

Office jobs, computers, cars and gadgets have created a more sedentary society which requires fewer calories to be burned. People can offset their less active working and domestic environments by eating fewer calories or burning more calories in their leisure time, but not everybody does. Hence the rise in obesity in recent decades. It cannot be assumed that those who engage in leisure-time exercise are more physically active than previous generations, and it certainly cannot be assumed that the leisure-time exercise of a minority makes the sedentary majority less likely to become obese.

The evidence is quite clear that, on average, calorie expenditure has declined over the years in developed countries. Public Health England (who say that the ‘link between physical inactivity and obesity is well established’) report that ‘People in the UK today are 24% less active than in 1961’. The World Health Organisation has remarked on the ‘trend towards decreased physical activity levels due to the increasingly sedentary nature of many forms of recreation time, changing modes of transportation, and increasing urbanization.’ Harvard School of Public Health says that ‘Physical activity levels are declining’ and that ‘this decline in physical activity is a key contributor to the global obesity epidemic’.

Even this demonstrable fact is disputed by the revisionists. Fung cites a study of hunter-gatherers as evidence that modern man burns the same number of calories as our ancestors. There are a number of problems with this interpretation (see here for a few) and other studies of hunter-gatherers have found significantly higher energy expenditure, but it is not necessary to speculate about prehistoric man for us to see that calorie consumption has fallen over time.

In his 1946 essay, The Politics of Starvation, George Orwell noted that the average Briton was eating ‘about 2,800 or 2,900 calories a day’ despite rationing and a shortage of food that was on the verge of leading to civil unrest. This would be enough to fatten up most Britons today, which is why we are advised to eat just 2,000-2,500 calories a day.

This was not journalistic licence on Orwell’s part. Two years later, the British Medical Journal published a study which found that the average Briton lost weight if he consumed fewer than 2,900 calories. Unless you believe that human metabolism has evolved dramatically in the last 70 years, the only explanation for our grandparents eating more yet staying slimmer is that they burned more energy in their daily lives.

Few people joined a gym in the 1940s. They didn’t need to. Today, there are lots of gyms and lots of obese people, but this is not proof that physical activity is useless in preventing weight gain. Asking whether leisure-time exercise leads to weight loss is a much narrower question than asking whether physical activity is linked to obesity, but to answer it we need to look at the people who are exercising, not at the whole (largely sedentary) population. In the next post, we will do just that.

Part Three

Now let’s look at the effect of exercise on individuals. Fung – who coined the term ‘Calorie Reducation as Primary’, or CRaP, to describe ‘current obesity thinking’ – is unequivocal. In a series of blog posts entitled ‘The Myth about about Exercise’, he writes: ‘There are many benefits to regular exercise. Weight loss, though, is not one of the benefits‘ (italics in the original).

He cites three studies which found that burning off a certain number of calories did not result in a commensurate loss of body weight. He rightly attributes this to a degree of compensatory eating. In other words, exercise creates appetite which can lead to more calories being consumed.

But, in making this point, he downplays the conclusions of the studies themselves, all of which also make it clear that the participants who exercised lost a significant amount of weight.

The first of these studies concluded that ‘physical activity expressed as energy expended per week is positively related to reductions in total adiposity’. The second found that people who exercised most intensively did not lose more weight than people who trained less intensively, but the crucial fact remains that all the subjects who trained lost more weight than those who didn’t. All exercise groups had a significant reduction in waist circumference. Similarly, the third study concluded that ‘supervised exercise, with equivalent energy expenditure, results in clinically significant weight loss’.

By the time he gets to his third ‘Myth of Exercise’ post, Fung has almost given up on his claim that ‘there is no measurable association between obesity and physical activity’ and is instead arguing that exercise is merely less effective than dietary change.

He cites a 2007 study involving people who exercised for around 45 minutes a day. After a year, their body mass index (BMI) had dropped by 0.5 and 0.6 (for men and women respectively) while the BMI of the control group either rose or stayed the same. Moreover, those who exercised the most lost the most weight.

Fung views this amount of weight loss as trivial, saying: ‘Colour me unimpressed. Exercise is just not that effective for weight loss.’ That’s a matter of opinion, but it’s rather different to claiming that weight loss is not one of the benefits of exercise.

As the killer blow, Fung discusses marathon running, which he evidently sees as the ultimate test of the exercise/weight loss hypothesis. He relishes the chance to talk about a 1989 study of people who were training for one:
Endless chub rub (chafing between the inner thighs). Miles upon miles on the dreadmill.  But so worth it, right?  Average body fat loss for men …  5 pounds.  Average weight loss for women … zero.

What Fung doesn’t mention is that this study was not aimed at achieving weight loss and there is no evidence that the participants wanted or needed to lose weight.

The men had a healthy average BMI of 23.4 before they started training and the women were a slender 21.1. Both groups consumed significantly more calories while training, mainly from carbohydrates, and both groups actually did lose weight. The men lost an average of 2.7 kg and the women lost 0.9 kg, though the latter was not statistically significant. Both groups also lost fat as a percentage of body weight (from 16.6 to 13.4 per cent for men and from 24.9 to 23.6 per cent for women) although there were were too few participants for these results to reach statistical significance.

The literature on physical activity is very large and Fung is entitled to select any part of it to make his case, but if these studies debunk the claim that exercise helps people lose weight then you can only wonder what the rest of the literature says.

Unsurprisingly, other studies make the case for physical activity even more convincingly. Listing a few in chronological order:

• A randomised control trial published in 2000 found that ‘weight loss induced by increased daily physical activity without caloric restriction substantially reduces obesity’.

• A 2003 study from the US found that ‘moderate-intensity exercise sustained for 16 months is effective for weight management in young adults.’

• A 2004 study of overweight women from Singapore found that an eight-week exercise programme ‘significantly reduced body weight, body mass index, percentage body fat and waist circumference’.

• A 2005 review concluded that ‘Regular exercise can markedly reduce body weight and fat mass without dietary caloric restriction in overweight individuals.’

• A 2009 study of middle-aged women found that ‘body mass, body composition, waist circumference, and high-density lipoprotein cholesterol changed favorably’ after a 30 minute, five days a week exercise routine.

• A 2009 study of younger women found that physical activity was ‘associated with a reduction in long-term weight gain, and greater duration is associated with less weight gain’. Moreover, it found that ‘sedentary behavior independently predicted weight gain.’

• A 2012 study found that a moderate-intensity exercise programme reduced BMI by 2.4 per cent amongst post-menopausal women, rising to 10.8 per cent if combined with a reduced calorie, low-fat diet.

• A 2013 study from the US concluded that ‘supervised exercise, with equivalent energy expenditure, results in clinically significant weight loss’.

I could cite many more studies (and have before) but there is no point in labouring a point that should be obvious: if you burn off calories they cannot turn into body fat.

The simple, unavoidable fact of human physiology is that you can’t lose weight without creating a calorie deficit. Whether you do this by eating less, moving more or a combination of the two is a matter of preference. Some people may find it too difficult to change their diet while others may find it too difficult, or too time consuming, to start exercising. Some find it easy to cut out alcohol or sugar, while others find it easier to play more sport.

Since nobody denies that physical activity has health benefits that extend beyond weight management, it could be argued that a calorie burned is better than a calorie foregone, but the crucial thing is to eat fewer calories than you burn. If your preference is for radical dietary change then by all means make your case – but don’t let your interest in ‘calories in’ blind you to the importance of ‘calories out’.

Monday, 19 July 2021

The Pioppi Diet is a superficial lifestyle guide based on distorted evidence

First published by Spectator Health in July 2017

Pioppi is a very small village in southern Italy. It is one of those places where people are reputed to live much longer than average (the authors claim life expectancy is 89 years but do not provide a citation for this claim). The gimmick behind this book is that the authors have travelled to the village, bottled its secrets and are prepared to sell them to you for a small fee.

Since the authors are both advocates of the low carb, high fat (LCHF) regime, everything is seen through the prism of the Atkins diet. They are Aseem Malhotra (a cardiologist, as he never tires of reminding you) and Donal O’Neill (director of internet-only, anti-carbohydrate movies such as Cereal Killers and Run on Fat).

In some respects, Pioppi is a surprising place to find this low carb duo as it was the home of the scientist Ancel Keys who died in 2004 at the age of 100. It was Keys who drew the world’s attention to the villagers’ longevity when he was conducting research into nutrition in the mid-twentieth century. That research helped to create the evidence that linked saturated fat to heart disease, and low carb activists have spent years portraying him as a crackpot and a bully who was probably in the pay of Big Sugar and who definitely blackmailed the scientific community into unfairly ‘demonising’ saturated fat. As a result of his junk science, they say, governments around the world changed their dietary guidelines to encourage the consumption of carbohydrates at the expense of life-saving lard. The general public, slavishly following government advice as always, took this as a green light to stuff their faces with sugar and soon became obese.

It’s a bizarre and ahistorical conspiracy theory which, as Anthony Warner says in The Angry Chef would require ‘paying off the medical establishment, the World Health Organisation, numerous charities, public health bodies and nutrition researchers around the world, and keep producing systematic reviews that show links between consumption of saturated fats and increased risk of heart disease.’ The idea that millions of people have been killed by guidelines which (a) were never followed, and (b) clearly discouraged sugar consumption, is one of the strangest memes in the world of nutritional woo.

Pioppi is at the very centre of the nutritional orthodoxy. Not only did Ancel Keys live there for many years, but it is recognised by UNESCO as the home of the Mediterranean Diet. In a sense, The Pioppi Diet is an attempt to erase the legacy of Keys and reclaim the village for the one true faith of LCHF. Keys attributed the Pioppi residents’ low rates of heart disease to the relative scarcity of saturated fat in the Mediterranean diet, but as far as Malhotra and O’Neill are concerned, saturated fat has been exonerated and their job is to discover what is really going on there.

Reading between the lines of The Pioppi Diet, it’s reasonably obvious what’s going on. It’s a rural farming and fishing community of 200 people who are engaged in manual labour from a young age and remain physically active throughout their lives. The air is clean and the local diet is dominated by fruit, vegetables, fish, pasta, olive oil and wine. The villagers have traditionally been too poor to eat a lot of red meat. Indeed, they have been too poor to eat a lot of anything, hence the low rate of obesity and its associated diseases.

The longevity of the Pioppi people is therefore entirely consistent with mainstream science and yet it forms the backdrop to a book which tells the reader to be ‘prepared for everything you know and believe to be true to be turned on its head’. But it is only a backdrop, a blank screen onto which they project whatever thoughts come to mind. They visit the village but do not conduct any research there. Instead, they stroll around drinking coffee, admiring the noble peasants and making sagelike comments such as ‘There’s not much sign of stress around here, Aseem.’

The first half of the book sees them take it in turns to crowbar in all the LCHF articles of faith: physical activity won’t help you lose weight, saturated fat is good for you, cholesterol is nothing to worry about, sugar is a poison, a calorie is not a calorie, etc. I have neither the time nor inclination to fact-check all of their claims so I will allow for the possibility that they might be right from time to time. I am quite prepared to believe that the dangers of saturated fat have been overstated; better qualified people than Malhotra and O’Neill have been critical of the evidence for years. But whenever they touch on a topic with which I am familiar, I noticed that their discussion of evidence was partial and one-sided, and sometimes totally incorrect. On the occasions when I felt moved to follow up their (rather patchy) references, I nearly always found that there was less to them than meets the eye.

For example, Malhotra cites the PREDIMED study, a well-regarded piece of research which appeared to show significant benefits from the consumption of nuts and olive oil. But it did not, as Malhotra claims, show the superiority of a high-fat diet over a low-fat diet; such a hypothesis was never raised nor tested. He also cites the Lyon Diet Heart Study as evidence that ‘the standard American Heart Association recommended “low-fat diet”‘ causes more heart attacks than the Mediterranean Diet. The study does indeed show benefits from the Mediterranean Diet, but it is only by reading the study that you would see that the Mediterranean Diet was lower in both total fats and saturated fats than the ‘standard’ diet.

Some of the errors in the book are risible, such as when they claim that in ‘industrialised countries between 5 and 10 per cent of GDP is spent treating dental disease’ (the entire NHS budget takes up 9 per cent of GDP). Others are just sloppy, such as when they use a graphic from a newspaper to prove that poor diets cause 35 per cent of deaths (they don’t). Nearly all of them are consistent with a systematic bias towards a desired conclusion.

The reader should not have to look up the references in a book to find out what is being concealed. The nutritional epidemiology literature is enormous. Thousands of studies have been conducted and they do not all agree with one another. If one ignores the totality of the evidence and cherry-picks a handful of studies, it is possible to argue almost anything. If the reader cannot trust the author to play with a straight bat, he might as well save his money and go on a Google binge.

Take the chapter on sugar, for instance. The scientific consensus says that obesity is a risk factor for diabetes. Insofar as there is a link between sugar and diabetes, it is the same as the link between cheese and diabetes, ie. if you eat to much of it, you will become obese and therefore be at greater risk of diabetes. It is indirect.

A handful of dissenters claim that there is a direct link and that sugar can cause diabetes even in the absence of obesity. The most famous of them is Robert Lustig, a Californian endocrinologist who has views on sugar that are extreme by any standard. He has made various wild claims about sugar being ‘toxic’ and ‘addictive’. He calls it ‘the alcohol of the child’. Amongst other strange assertions, he has said that breast milk is not sweet and that pasta was invented in America. His published research on sugar is, in my view, third rate and I don’t think anybody should take him too seriously. But he is on the low carb bandwagon and is one of Malhotra’s chums. Consequently, while the chapter on sugar only references five studies, four of them are by Lustig and his colleagues, although this is not obvious from the text.

Even if the scientific consensus is wrong and Lustig turns out to be a sort of Galileo, shouldn’t Malhotra at least acknowledge the totality of the evidence, even if only to argue against it? And if there is an independent association between sugar and diabetes, why do organisations that want people to eat less sugar – such as SACN and Diabetes UK – continue to deny it? Is everybody in the pay of Big Sugar?

Malhotra’s credentials as a cardiologist are not sufficient to persuade me to ignore so many scientists. He says himself that ‘the majority of doctors are not equipped with even basic training to give specific, evidence-based lifestyle advice’ and admits that he doesn’t recall receiving ‘a single lecture at medical school on the impact of nutrition and lifestyle on preventing and treating disease’. All of his conclusions, he says, are based on ‘my own research’. But there are experts in this field who have received ample training and have been given many lectures on nutrition. They are called dieticians, and I have yet to meet one who endorses Malhotra’s message.

It soon becomes clear that The Pioppi Diet is not a serious review of the evidence. It provides a distorted and superficial account of a tiny fraction of the evidence. It does not really attempt to overturn the scientific consensus, it simply ignores it. Meanwhile, it devotes page after page to a handful of low carb activists who are portrayed as world-leading authorities, such as Zoe Harcombe, Tim Noakes, Nina Teicholz, Jason Fung and Robert Lustig. While all these people have books to sell, Malhotra and O’Neill accuse ‘many scientists and doctors’, as well as the media, of being ‘under the financial influence of the food and pharmaceutical industry’. This, we are told, is why they ‘disseminate selected, biased and outdated information’. When your best evidence is a single study from 1956 which has never been replicated, this is a bit rich.

So what is this Pioppi Diet that promises a ‘life-changing journey taking just 21 days’? The first thing to understand is that it is not a diet, it is a lifestyle. From wandering around Pioppi, Malhotra and O’Neill come to the profound conclusion that it is important to socialise with friends, take plenty of exercise, be relaxed and get some sleep. They can’t help you with socialising or stress relief, but they suggest you get at least seven hours sleep (which is also what the National Sleep Foundation recommends). With regards to exercise, O’Neill spends several pages waxing lyrical about high intensity interval training, but is forced to admit that they don’t do that kind of thing in Pioppi and so recommends getting up from your desk every 45 minutes to stretch your legs.

So much for the lifestyle. What about the food? Malhotra and O’Neill recommend that you avoid desserts, all sugars (including fruit juice and honey) and many of the most common sources of calories, including bread, rice, pasta, cereals, potatoes, noodles, couscous and ‘anything flour based’. You should also fast for 24 hours once a week and think about skipping breakfast every day (because the authors were told that Pioppi people used to be so poor that they sometimes went to work hungry). If you do all this, plus lots of walking and go to the gym five times a week (as Malhotra does) or engage in regular high intensity training (as O’Neill does), they reckon you will lose weight. And do you know what? I think they might be right. Behold the miracle of the Pioppi Diet!

The trouble with this whole concept is that Malhotra and O’Neill’s interpretation of the Pioppi Diet does not reflect what the people of Pioppi eat. It is basically an ultra-low carb version of the Mediterranean Diet with a few trendy ingredients, such as coconut oil, thrown in. Coconuts have never been part of the Italian diet and nor have ‘full-fat fermented dairy products’ but the authors include the latter anyway because – as they say – ‘the Greek cohort in Ancel Keys’s original studies enjoyed [them] … so there is no reason we shouldn’t be doing likewise!’

Do you know what the people of Pioppi actually eat? Processed carbohydrates. Farm workers in rural Italy do not – could not – survive on a diet of fish and seasonal vegetables. Pasta is as central to the Italian diet as potatoes are to Britain’s. So too is bread. This is the elephant in the room for anyone trying to pretend that Italians eat a low carb diet. As a 94 year old Pioppi resident said last year: ‘Pasta is my favourite food. I don’t understand why so many people try to cut that and bread out of their diets – it is like medicine for the heart and it is silly not to eat it.’

Once you accept that pasta and bread are important elements of Mediterranean cuisine, the actual Pioppi diet involves lots of fruit, vegetables, fish, starchy carbohydrates, mushrooms, nuts and eggs, but little or no cake, biscuits, processed meat, crisps and red meat. In other words, it is the UK government’s Eatwell Guide with extra virgin olive oil. Maybe those official dietary guidelines are not so deadly after all?

Will childhood obesity ever be measured properly?

I've written for Spiked about the good part of Henry Dimbleby's report which nobody noticed...

Henry Dimbleby has taken some flak for his National Food Strategy report, which called for taxes on sugar and salt in the aftermath of the deepest recession in 300 years when inflation is already rising. Some people have unkindly portrayed this as one overweight, Oxford-educated Etonian telling another overweight, Oxford-educated Etonian to make the poor pay more for food. Others have noted that Leon, the fast food chain founded by Mr Dimbleby, is a major purveyor of salty, fatty and sugary products. His idea of getting GPs to prescribe fruit and vegetables has been mocked as preposterous.

Reader, I confess that I have been party to this mockery, but I come here today not to bury Mr Dimbleby but to praise one small aspect of his report. 
Dimbleby has noticed the weird decline in 'obesity' when children become adults. As regular readers know, this is because we measure childhood 'obesity' in a farcical way that classifies millions of slim children as fat. 

Sugar consumption has been falling for years

First published by Spectator Health in October 2015

Public Health England’s long-awaited report on sugar was published yesterday. I say ‘long awaited’ but hardly anybody had heard of it until last Monday when Sarah Wollaston created a storm in a teacup by claiming it had been suppressed by the government. As Wollaston must have known, and as the media has gleefully reported this week, it included a tax on sugar among its recommendations.

Many people seem to have misunderstood the purpose of the Public Health England report. It was not intended to be a cost-benefit analysis of anti-obesity policies. It was focused entirely on how sugar consumption could be reduced at the population level. Since that was its only aim, it is not surprising that a sugar tax was suggested as a possibility — albeit only the fourth best possibility, in the view of its authors.

If I had been forced to write a report about how the consumption of sugar — or any other product — could be reduced, I would have mentioned taxation as well. The law of demand, arguably the most basic concept in economics, is an obvious place to start. Nobody has ever denied that higher prices tend to lead to less consumption. The argument against a sugar tax is not that it would have no effect on demand, but that the effect would be trivial, the impact on obesity would be virtually non-existent and the impact on consumers would be negative and regressive.

The authors of the Public Health England report did not weigh up the pros and the cons of a sugar tax because that is not what they were charged with doing. They did not need to look at the consequences, except those related to consumption. They did not even ask whether less sugar consumption would lead to less obesity, they simply assumed that it would. In one of the Annexes to the report, they explicitly state that they had ‘very little insight’ into a host of issues, including the ‘difference in short- and long-term effects, the extent and nature of a regressive (and progressive) effect and an understanding of compensatory behaviours and their impact on individual and population level dietary intake and nutritional quality overall’ — in other words, all the issues you’d need to look at to make a balanced judgment.

A report that recommends a sugar tax without looking at the impact on dietary intake or the economic impact on the poor is a one-sided effort, to say the least. If you take a rose-tinted view of the benefits and ignore the costs, any policy will seem attractive. Fortunately, politicians have so far taken a broader view and have rejected the idea of a sugar tax. Let’s hope they hold their nerve.

It is worth asking why Public Health England is so insistent on reducing our sugar consumption in the first place. On page 27, we get this slightly unnerving explanation:
‘What we eat now is very different to what we ate 30 or 40 years ago. As a result of advances in technology, economic development and other factors the food and drinks market has evolved to provide more choice than ever before. We are constantly nudged towards buying and eating more food — our environment is filled with more food outlets (shops, restaurants, takeaways and fast food restaurants, cafes and coffee shops) and, in real terms, food is cheaper than ever before.  
‘We now spend significantly less every week on our groceries — between 1957 and 2006 the proportion of our average weekly expenditure spent on food and non-alcoholic drinks has halved from 33 per cent to 15 per cent which is good for household budgets but not necessarily so good for our food choices. While none of this is anyone’s fault, it’s time to change this and influencing our overall supply of food and drink is critical so that improvements are made to what is available to us and what we actually eat.’

This tells you a great deal about the mentality of the ‘public health’ lobby. They are strangely attracted to scarcity and want. For example, they have a peculiar fetish for how Cuba made people slimmer through poverty. What we see in the paragraph above is an account of economic progress as a Bad Thing. We have ‘more choice than ever before’, we have ‘more food outlets’ and ‘food is cheaper than ever before’. Food poverty has been virtually eradicated and our grocery bill is now a small fraction of our weekly outgoings. But rather than celebrating this triumph over scarcity, Public Health England portrays it as a step backwards and asserts that ‘it’s time to change’.

‘None of this anyone’s fault’, they say, as if we might be tempted to point the finger of blame! Has it really come to this? Do we really have to feel bad about having more choice, lower prices and more disposable income?

Besides, where has all this economic progress left us? According to Public Health England, the food we eat today is ‘very different to what we ate 30 or 40 years ago’. They do not go into detail about what the differences are, but they do provide a citation to a Defra report entitled Family Food 2013 which notes that ‘energy content of food purchases has been on a downward trend since 1965’ and ‘energy intake per person declined 31 per cent between 1974 and 2013’.

If you dig around in Defra’s source material, you can see that sugar consumption has declined by 16 per cent since 1992. This is confirmed by data on the availability of sugar which shows a decline of about 20 per cent since the 1970s. It is also confirmed by the National Diet and Nutrition Survey and the Nutritional Survey of British Adults. We can argue about the exact size of the decline, but all the evidence points in the same direction. We eat less sugar today than we did in Public Health England’s shangri-la of 30 or 40 years ago.

This, of course, is contrary to popular perceptions, but every popular perception about sugar is contrary to the evidence at this time of mass hysteria.

Friday, 16 July 2021

Denmark’s fat tax was a failure — but revisionists are trying to rewrite the story

First published by Spectator Health in August 2015

The short tale of Denmark’s ‘fat tax’ can be easily told. After being voted for by an overwhelming majority of MPs, the tax on saturated fat led to inflation, cross-border shopping, job losses and huge administrative costs. It had very little effect on the consumption of saturated fat because Danish shoppers downgraded to cheaper brands from budget supermarkets, often in cheaper countries. It did, however, clobber the poor — as indirect taxes usually do. Since it had a negligible impact on consumption, it is unlikely to have had any impact on health. Once it became clear that the fat tax was creating lots of costs and no benefits, an overwhelming majority of MPs voted to repeal it. In January 2013, 15 months after it was introduced, it was abolished.

A couple of years ago I wrote a brief history of the Danish fat tax for the Institute of Economic Affairs, so it is with interest that I have watched history starting to be rewritten in recent months. An article in the European Journal of Clinical Nutrition earlier this year claimed that the tax was more effective than was previously thought. The authors claimed that the sale of fatty products fell by 10 to 15 per cent as a result of the tax and that the ‘intended effect on fat consumption appeared to have been achieved’. They concluded that the tax was introduced primarily for economic reasons and that if the Danes had stuck with it as a serious health policy, they would have reaped the rewards. This view was echoed in an opinion piece in last week’s British Medical Journal, which repeated the claim that consumption fell by 10 to 15 per cent and asserted that the tax was repealed as a result of ‘worries about border trade and lobbying by industry’, rather than the serious and widespread concerns that were reflected in Danish newspapers at the time.

The only part of this revisionist history that stands up to scrutiny is the role of economic concerns in bringing about repeal. There is no doubt that the tax was abandoned, in large part, because it was inefficient, ineffective and unfair. And why not? Yes, the food industry lobbied against the tax when it was in place, but they had been lobbying against it for several years before it was introduced — with no success. The tax was not abolished because the food industry suddenly became more powerful, but because ordinary Danes could see it failing before their very eyes.

It is simply wrong to assume that the fat tax was introduced for financial reasons. The Danish fat tax was unusual in being explicitly revenue-neutral from the outset. It was carefully calibrated to bring in just enough money to make up for a lowering of income tax that took place at the same time. In the event, it brought in more revenue than was expected because it didn’t reduce saturated fat consumption as much as the computer models had predicted, but it was never intended to increase the overall tax burden. It really was a health policy, first and foremost, but even if it had been a money-making scheme, this wouldn’t explain why it was ditched. It was very successful in bringing in money.

The key claim of the revisionists is that sales of fatty products fell by 10 to 15 per cent figure as a result of the tax. This figure comes from a study that looked at sales of butter, margarine and cooking oils in the first three months of the tax’s existence. The study did indeed show a fall of 10 to 15 per cent in those early days but there is a simple explanation for this. Knowing that the tax was to be introduced on 1 October 2011, thrifty Danes stockpiled fatty products in advance. The extent of the hoarding is shown in the graph below. Note the massive spike in sales just before the tax was introduced.

Having filled their fridges and cupboards with butter and oils, Danes had no need to buy more for a few weeks, but you can see from the graph that sales had returned to their pre-tax level by Christmas. The 10 to 15 per cent drop was therefore a temporary decline in the sale of certain very high fat goods as a result of previous hoarding. It is wholly misleading to present it as a permanent drop in the sale of products containing saturated fat as a result of the tax.

A more recent study looked at the whole 15 months during which the tax was in effect and found that the sale of products containing saturated fat declined by a mere 0.9 per cent. The study also looked at the impact on heart disease — the key health indicator — and found it to be negligible at best. One estimate suggested that heart disease risk increased by 0.2 per cent whereas another suggested that it declined by 0.3 per cent. Either way, we are in the realm of rounding errors.

The reality is the tax had little or no effect on dietary habits, obesity and health. It failed to do what it was supposed to do and so the Danes sensibly got rid of it. No amount of revisionism will change that, but it is not hard to guess why the story is being rewritten. Sugar has now replaced saturated fat as the health scare du jour and the conspicuous failure of the Danish experiment casts a long shadow over attempts to bring in a sugar tax. Politicians know it didn’t work. Worse still (for the campaigners), politicians know it was very unpopular. It failed and was seen to fail. The ‘public health’ lobby is pretty good at presenting damp squibs as great successes after the fact (minimum pricing in Canada and plain packaging in Australia spring to mind). Their job now is to do the same thing with the Danish fat tax.