Correcting Lockdown Sceptics

Will Jones at the Lockdown Sceptics blog has responded to my Quillette article about the corona-crazies. It's the usual stuff, but let's try one more time to put it to bed. 

 

The post is headlined, rather weirdly, 'Is Christopher Snowdon an anti-vaxxer?' because Jones thinks he has a savage burn to deliver.

Christopher Snowdon is plainly an anti-vaxxer, however well he tries to hide it. “Existing Covid vaccines are simply not good enough at preventing transmission and infection,” he writes. Hasn’t he read the trial results, showing 95% efficacy against infection for the Pfizer vaccine and 74% for the AstraZeneca vaccine? Or the large population study from Israel showing Pfizer’s 92% efficacy? Or the study from Public Health England showing 67% and 88% vaccine efficacy against the Delta variant for AstraZeneca and Pfizer vaccines respectively?

 

On what does he base his bald assertion that they are “not good enough at preventing transmission and infection”? Clearly not the science.

It's based on Public Health England's weekly vaccine surveillance report.

 

 

Jones continues...

 

He doesn’t appear to feel it necessary to give a single scientific reference for a claim that flies in the face of all these respectable studies, leaving the baffled reader assuming he must have picked it up in some article he read on an obscure website somewhere, presumably by a pseudo-scientific sceptic in denial.

 

I thought it was common knowledge. We can also look at heavily vaccinated countries such as Iceland, Malta and Israel which have recently seen new outbreaks and therefore have clearly not reached herd immunity.

As it happens, I agree with Christopher that the current vaccines are not very good at preventing infection or transmission, particularly now the Delta variant is in town. But I’m also aware that that is not the current mainstream scientific position (though it is based on recent official data and reports).

It is the current mainstream scientific opinion. The Delta variant has pushed the herd immunity threshold into the high 90s which is not going to happen and, as Professor Francois Balloux of UCL recently said, “the vast majority of the global population is expected to get infected by the virus, likely more than once over their lifetime.”

 

It seems, then, that Christopher is not averse to a spot of ‘crankery’ himself. But how helpful really is all this name-calling, mudslinging and smear by association? Science does not advance by consensus, by everyone agreeing, or by closing down dissenters. Christopher himself is evidently sceptical of one of the key mainstream vaccine claims – that they are highly effective against infection and transmission – so inadvertently places himself within the ambit of his own polemic. Indeed, at one point he fires a shot at the ‘smileys’, as he calls sceptics, for being sceptical of the vaccines, arguing the jabs “have been tested in clinical trials and have demonstrated their safety and effectiveness beyond reasonable doubt in recent months”. Yet he himself goes on to doubt their effectiveness!

Jones must think this is a killer argument because he spends so much time on it. However, like many smiley arguments, it is based on a simple misunderstanding. The vaccines are highly effective at preventing severe disease and death. They are not as effective in preventing transmission and infection, as the table above shows.

 

The science of Covid is far from settled. Snowdon takes aim at some of the more colourful and dubious characters in the sceptic camp (criticising some claims I have no wish to defend, though he is hardly kind or charitable as he does so). But he notably leaves out of his cranky panorama some of the world’s most eminent scientists who take a sceptical line on a number of the issues he raises.

 

Sunetra Gupta, for instance, Professor of Theoretical Epidemiology at Oxford University; Martin Kulldorff, Professor of Medicine at Harvard University; Jay Bhattacharya, Professor of Medicine at Stanford University. 

 

... Or where is Professor Carl Heneghan, Director of the University of Oxford’s Centre for Evidence-Based Medicine; or Sucharit Bhakdi, former Chair of Medical Microbiology at the University of Mainz; or John Ioannidis, Professor of Medicine, Health Research and Policy at Stanford University?

I don't want to get into the credentials game but it would be a stretch to describe any of these as the world's most eminent scientists. Even if they were, eminent scientists can be wrong, as Gupta was when she claimed that up to 68% of the UK's population had already been infected with Covid-19 by 19 March 2020 and that Covid's infection fatality rate was 'somewhere between 0.1% and 0.01%'.

 

Heneghan has also been frequently wrong during the pandemic and is one of a number of prominent sceptics to have deleted all his tweets during the second wave.  

The heart of the sceptical position on lockdowns, shared by all these scientists, is that they are not worth it.

That was the heart of the issue a year ago before the whole thing descended into pseudo-science, anti-vax quackery and conspiracy-minded wibble.

 

Christopher makes a number of specific claims in his piece that he seems to think are scientifically incontestable but in fact stand on very wobbly ground when given closer attention.

For instance, he asserts that the second wave in the U.K “lasted longer and killed more people”.

There were more Covid-related deaths between December 2020 and February 2021 than there had been in the first 11 months of the pandemic. At its peak, there were nearly twice as many people in hospital with the virus than there had been in March 2020. In Britain, as in most European countries, excess mortality went through the roof.

The data, however, tells a more complex story. Looking at the weekly total deaths, it’s clear that the second peak is much lower than the first (see below). The higher Covid mortality in winter compared to spring can be seen (blue bars) to be due to more of the non-excess deaths in winter being classed as Covid, whereas in spring there were many excess deaths beyond those defined as Covid (green bars). This discrepancy will likely have a number of factors behind it, but you have to think that how many people were being tested and treated as a Covid case has to play a large part, given that a Covid death is defined as a death from any cause within 28 days of a positive Covid test.

 

Note also that because it was winter the baseline was higher, meaning in percentage terms the excess peak was less than half the spring peak. This helps to put the winter epidemic into perspective.

The reason 'more of the non-excess deaths in winter [were] classed as Covid' is that they were caused by Covid. There were fewer non-Covid, non-excess deaths in winter because lockdowns, masks and social distancing got rid of the flu and the restrictions may have prevented some other deaths (what happened to the 'lockdown deaths' by the way?) 

 

It's debatable whether the peak really was higher in April - three of the four deadliest days of the pandemic were in January - although the peak in excess deaths certainly came in the spring. But I'm not talking about the peak. I'm talking about the overall number of Covid deaths. Even a cursory look at the graph above (which ends in February for some reason) tells you that there were more Covid deaths in the second wave than in the first.

Jones repeats the old smiley canard that 'a Covid death is defined as a death from any cause within 28 days of a positive Covid test'. Assuming he is not being deliberately misleading, it is kind of pathetic that he still doesn't know that the ONS data is based on death certificates. It is not based on the rough and ready estimates published on the dashboard which rely on deaths recorded within 28 days of a positive test. If you look at the death certificate figures, there are 24,000 more deaths than if you use the 28 days measure, and we know that around 90% of these deaths had Covid as the underlying cause.

 

It is very likely that some Covid deaths in the first wave were not identified as such due to a lack of testing, but this does not change the basic conclusion. There have been over 150,000 Covid deaths in England during the pandemic (according to death certificates). Only around 40,000 of them occurred in the first wave.

 

Just to remind you, the Lockdown Sceptics blog repeatedly claimed that there would be no second wave and that the pandemic ended last summer.

 

The below average deaths since the end of winter have also meant that 2021 is now a below-average year for age-adjusted mortality (so far), the low mortality of the spring and summer having already cancelled out the high mortality of January and February.

Look at the graph he uses to illustrate this! Does it look like the 'low mortality of the spring and summer' has 'cancelled out the high mortality of January and February'?! There have been several weeks when there have been fewer deaths than average, as you might expect after a virus has wiped out 150,000 people, but those dips are far smaller than the peaks in January and February. 

Jones links to one of his own crackpot blog posts (titled 'What pandemic?') to support his claim that '2021 is now a below-average year for age-adjusted mortality'. This is based on data from the Institute and Faculty of Actuaries. Read this thread from an actuary to see why Jones' interpretation is wrong.

Christopher is very critical of sceptics for questioning the reliability of the PCR test and the definitions of Covid case and death based on it. But this was a very live topic in autumn 2020, with a number of top scientists including Professor Carl Heneghan wading into the fray, as this correspondence in the BMJ records. The Lancet published a piece from NHS scientists in December stating that the operational false positive rate of PCR testing was estimated to be “somewhere between 0·8% and 4·0%”. 

 

The 'correspondence' is a Rapid Response on the BMJ (otherwise known as a reader's comment) and is worth clicking on as a reminder of some of the garbage being spouted by smileys in late 2020. The author claims that Covid is no more deadly than seasonal flu, that 'deaths are currently running at normal levels' (in mid-November) and that 'there is no sound evidence of any second wave'. It was written by this person. Needless to say, their Twitter output is a sewer of conspiracy theories, quackery and anti-vaxxing.

As for the Lancet article (a comment piece), I am very familiar with this because smileys frequently link to it despite it being from last September. It is only popular with 'sceptics' because it says 'preliminary estimates show [the false positive rate] could be somewhere between 0·8% and 4·0%.' It cites a SAGE document from early June 2020 for this claim. Smileys have clearly never read it because the document also says: 

DHSC figures [3] show that 100,664 tests were carried out on 31 May 2020 (Pillar 1 and 2 RT-PCR tests). 1,570 of those tests were positive for SARS-CoV-2 (1.6%). The majority of people tested on that day did not have SARS-CoV-2 (98.4% of tests are negative). When only a small proportion of people being tested have the virus, the operational false positive rate becomes very important. Clearly the false positive rate cannot exceed 1.6% on that day, and is likely to be much lower.

This is the obvious point that sceptics keep missing. The false positive rate cannot be higher than the positive rate. The world has been engaged in mass testing for over a year now. We do not need to rely on a preliminary assessment from last June. 

 

Why would the 'sceptics' rely on a document that is over a year old when they could look at more up-to-date evidence? It is because no credible scientists believes that the false positive rate is anywhere near 0.8%, let alone 4%.

The Office for National Statistics says:

 

We know the specificity of our test must be very close to 100% as the low number of positive tests in our study over the summer of 2020 means that specificity would be very high even if all positives were false.  For example, in the six-week period from 31 July to 10 September 2020, 159 of the 208,730 total samples tested positive. Even if all these positives were false, specificity would still be 99.92%.

 

Case closed.

Christopher argues: “The UK had a positivity rate of just 0.2% as recently as two months ago [May]. The false positive rate cannot possibly be higher than the positivity rate, but this simple logic continues to elude the Covid-sceptical community.” This simple logic is too simple, however, as it doesn’t grapple with the fact that the operational false positive rate can vary, including with the volume of tests.

Jones links to a blog post by "pathological" Claire Craig to support this false claim. Truly desperate stuff. 

Christopher claims U.K. infections fell in January because of the lockdown, but fails to engage with the fact that Sweden’s fell as well without a lockdown.

They did indeed. And then they rose again, as I say in the article. Lockdown sceptics are fond of saying that infections fall before lockdowns begin. This is usually untrue, but even when it has happened (as it did before England's most recent lockdown) there is no guarantee that rates would have continued to fall if a lockdown hadn't been enacted. Sweden is a good example of a post-Christmas decline turning out to be a false dawn. 

Jones tries to wriggle out of this by not showing the infection data and only showing the mortality data. He claims that too few people were vaccinated in Sweden for vaccines to have reduced the death toll in the third wave. I disagree, but whatever the reason for the lower mortality after February, Sweden had a high infection rate throughout winter and spring as well as a high rate of hospitalisation. The charts below shows case numbers and intensive care admissions for Covid.

Sweden and the UK are different countries and one cannot be treated as a control group for another, but comparing their outcomes in winter and spring is a priori evidence that lockdowns work. As a major travel hub with many big cities, the UK has been hit harder by Covid from the start. If the UK had followed Sweden's trajectory, it would have been disastrous.

Inevitably, he then brings up Florida and makes the usual comparison with California as if a state on the other side of the continent was the only available comparison. He talks about 'lockdown states' as if it were a binary choice between being in lockdown and being “open”. Most states haven't been in lockdown for a year and in reality there is a patchwork of local, city and county rules, Florida included. 

 

I am so bored of hearing about Florida that I cannot be bothered to discuss it again. I will just repeat that it is quite possible to keep R at or below 1 for a period of time without lockdowns. No one has every claimed otherwise. It is a non sequitur to say that this proves that lockdowns don't work. It doesn't even test the proposition. 

 

Lockdowns are only needed when the rate of infections gets so high that it threatens to overwhelm the health service and kill very large numbers of people. I remind you that Florida now has the highest infection rate in the USA, if not the world.

Jones repeats the smiley mantra that 'in England infections have peaked and declined prior to lockdown on all three occasions'. This is not true. Infections fell somewhat a few days before the first and third lockdowns but, crucially, not the second. The first and third lockdowns were preceded by heavy restrictions which reduced R. All schools, pubs, restaurants, theatres, gyms, etc. were closed several days before the first lockdown. Much of England was already in de facto lockdown long before the winter lockdown began, the hospitality industry was closed in most of the country and heavily restricted in the rest. All the schools were closed for Christmas. Many workplaces were also closed for Christmas. It is not surprising that the infection rate fell, but there is no guarantee that the decline would have continued after the Christmas holidays.

The second lockdown was not preceded by other measures and the infection rate only fell after it began. It beggars belief that anyone can look at the curves in autumn, with the pronounced dip in November, and believe that this is the natural waxing and waning of an epidemic. What possible reason can there be for a respiratory virus to suddenly decline in November when it was rising in October and rose again in December? 

The clincher is that there was a similar trend in Wales (below) but the dip started and ended two weeks earlier. In England, cases peaked on 11 November (five days after the lockdown began). In Wales they peaked on 29 October, six days after the Welsh lockdown began. 

 

 

It's an almost perfect natural experiment involving two neighbouring countries. It is very difficult to deny that the drop in infections was caused by the lockdowns but of course Jones does. He cites a study which is wrong for the reasons I explain here.

I realise that I am wasting my time responding to these people. Anyone who is still arguing about false positives 18 months into the pandemic is beyond help. The Lockdown Sceptics blog has been a major source of disinformation since it was launched last year and has likely led to the deaths of some of its readers. If you look at the comments section, you will find an absolute madhouse of paranoia and ignorance. Nothing short of intubation will bring them to their senses. Maybe not even that.

The WHO's crazy war on vaping

I've got an article in this week's Spectator about the World Health Organisation and its insane war on e-cigarettes. You can read it for free here.

 

It might be hidden from the eyes of the world, but a showdown between the pragmatists and prohibitionists beckons at COP9. With a delegation of its own now that it has left the EU, Britain has the opportunity to take a world-leading role in the promotion of science and good regulation. The British delegation is likely to include some ex-smokers who quit thanks to vaping and who will argue for the UK model of light-touch regulation and evidence-based messaging. If they succeed, our most successful post--Brexit export to date may not be a product, but a model that will save millions of lives.

However, if the WHO snubs Britain — which is the FCTC’s biggest funder — the organisation set up to improve global health could become one of its biggest threats.

I'm also on the Spectator podcast with Clive Bates to discuss it.

Return of the coronavirus cranks

In January, I wrote an article for Quillette about coronavirus cranks such as Ivor Cummins and Michael Yeadon. I've now written a follow up article to chart their descent into madness.

 

The fat lady had not just sung. She had sung, taken off her frock, had a smoke, and was in a cab home. But this produced no contrition or self-reflection from the sceptics. Instead, they just got crazier. Whether it’s using the Freedom of Information Act to find out how many cremations took place last year (a lot more than usual) or pestering authorities for details of PCR cycle thresholds, there is no barrel they won’t scrape. At the anti-lockdown protest in London on Saturday, David Icke accused “demons” of using “a fake virus, a fake test, and fake death certificates to give the illusion of a deadly disease that has never and does not exist.” The MC, a former nurse and current conspiracy theorist named Kate Shemirani, explained that “you cannot catch a virus—it was a lie manufactured by the Rockefellers.” Piers Corbyn—brother of the UK Labour Party’s last leader—emphasised the urgent need to “close the jab centres” and “take down 5G towers.” If those who attended were disappointed to find a rally against lockdowns and vaccine passports turn into a showpiece for anti-vaxxers and assorted lunatics, it was not obvious from their cheers.

Michael Yeadon now believes that COVID vaccines are being used by governments as “a serious attempt at mass depopulation.” He also appears to believe that taking the vaccine makes people magnetic. He is setting up a retreat in Tanzania called Liberty Places for “lockdown refugees” and is involved with Liberal Spring, a group that hopes to take over the Liberal Democrats. Liberal Spring’s logo is the pink flower—which has usurped the smiley-face as an indicator of online gullibility—and it calls on the Lib Dems to make 10 pledges, nine of which are related to COVID policy, such as holding “a public enquiry into the misattribution of COVID-19 deaths and data recording.” (The 10th, more sensibly, is to “avoid discussion about rejoining the EU.”)

The genuinely hilarious Naomi Wolf was suspended from Twitter in June for spreading bizarre anti-vax theories, including the idea that some COVID vaccines are a “software platform” which can “receive uploads” and that the technology exists for vaccines to make people travel back in time.

 

Do read it all.

The lying, incompetent World Health Organisation

Having done such a cracking job with COVID-19, the WHO has gone back to doing what it loves best - scaremongering about vaping. It has put out one of its infamous Twitter threads with the usual half-truths and outright lies.

 

The aerosols from e-cigarettes contain toxic substances that can cause

🚨 cancer
🫀 cardiovascular diseases
🫁 lung disorders
🧠 damage to children’s brain development#CommitToQuit e-cigarettes now for a healthier life!

Here's how 👉https://t.co/7OReiIXXpd pic.twitter.com/MvwAZqB8oB

— World Health Organization (WHO) (@WHO) July 27, 2021

 

As one wag said on Twitter, it's nice that the WHO has finally noticed the existence of aerosols (having denied that SARS-CoV-2 was airborne for so long), but they've taken it too far this time. 

 

What is the evidence for any of these claims? There is no epidemiological evidence that vaping causes these diseases. Even the report the WHO is promoting with this thread does not present any evidence that vaping causes cancer or heart disease. The only reference to lung disease is a reference to the 'popcorn lung' myth and the EVALI outbreak that was not caused by vaping nicotine. Let's be blunt about it. The WHO is lying.

That is hardly surprising since the report itself is brought to you by billionaire prohibitionist Michael Bloomberg. 

 

The chances of a report written by the WHO and funded by Bloomberg saying anything useful about e-cigarettes are negligible. Sure enough, it presents tiny and/or hypothetical risks as proven and proven benefits as hypothetical. In the process, it resurrects several objections to vaping from the stone age. Remember when anti-smoking groups said vaping needed to be banned indoors because it's hard to tell the difference between vaping and smoking (it isn't)? That's in there. Remember the nonsense about how vaping 'renormalises' smoking (it doesn't)? That's in there too. 

ENDS are harmful. For example, nicotine can have deleterious impacts on brain development, leading to long-term consequences for children and adolescents in particular (15).

Reference 15 is a speculative article based on a web search for information about oxidative stress which concludes that e-cigarettes "could potentially play a role in adolescent/young adults social maladjustments". Could potentially! 

 

Nicotine doesn't have a deleterious impact on adult brains (quite the reverse) and it is unlikely to have such an effect on a teenager's brain. In any case, the sale of e-cigarettes is banned to 'children' so it's irrelevant. 

And then we have the old chestnut about the gateway effect...

Children and adolescents that use ENDS are more than twice as likely to use conventional cigarettes.

This features prominently in the report and in the WHO's Twitter thread. If ever there were a case of correlation not equalling causation, it is this. Studies will keep finding this correlation until the cows come home because there is no way of controlling the results for an individual's like or dislike of nicotine, as Carl Phillips has expertly explained. 

As for the crucial matter of vaping being the most effective way to give up smoking in history, the WHO remains unconvinced, despite this question being the only one that has been answered by multiple randomised controlled trials and unmistakable real world evidence. 

This sums up the report. Any old supposition is good enough for the WHO is it suggests risk, but even the strongest evidence is downplayed or denied when it comes to benefits. 

Incidentally, this is also apparent in the chapter about Covid and smoking. After claiming that e-cigarettes 'are thought to play an unfavourable role in COVID-19 severity' and asserting that 'evidence on the biological mechanisms linking to COVID-19 and tobacco use is growing', the WHO addresses the small matter of dozens of epidemiological studies showing smokers are less likely to get COVID-19. Naturally, the WHO is unconvinced and provides a page of caveats and whataboutery to downplay these findings before demanding a 'large prospective cohort study' to prove it. 

Tellingly, they do not demand the same strength of evidence when claiming that vaping causes cancer or nicotine damages the brain - or indeed that 'smoking worsens Covid outcomes'. That's because this is not a scientific report. It is prohibitionist propaganda.

Earlier this week, Philip Morris called for cigarettes to be banned by 2030. Now the World Health Organisation has gone out to bat for the cigarette trade.

Funny old world. Funny old World Health Organisation.

Defund it.

Tobacco: Australia's new drug war

Let's take one of our occasional trips down to Australia to see how the World Leader in Tobacco Control is getting on with its staggeringly high cigarette taxes.

 

As authorities target illicit tobacco imports, criminal groups are turning their attention to farming their own crops across regional Australia.

Illicit Tobacco Taskforce Australian Border Force Commander Greg Linsdell said that in the past 12 months there had been a significant increase in seizures involving the domestic growth of illicit tobacco as criminal groups look to maintain their supply after COVID-19 impacted imports.

Incredibly, it has been illegal to grow tobacco in Australia for over a decade and you can get ten years in prison for doing so. People banned from growing plants? It sounds like the War on Drugs and that is basically what Australia is working towards with tobacco.

 

Unsurprisingly, it has led to all the problems you associate with the drugs war, notably rampant criminality and an industrial scale black market. 

 

Authorities are also contending with huge illicit tobacco importation attempts. In the most recent fiscal year until the end of May, the ABF seized 512 million cigarettes, a 36 per cent increase from the previous year. The force also seized 748 tonnes of loose-leaf tobacco, compared to 167 tonnes the previous year.

The 2020-21 haul is equivalent to an estimated $1.7 billion in evaded duty – a record amount, compared to an estimated $621 million in evaded duty from the previous year.

During the final week of May, the ABF intercepted almost 10 tonnes of loose-leaf tobacco and more than 7.3 million cigarettes via sea cargo.

 

It should never be forgotten that this is a totally avoidable political choice. If the government respected people's right to smoke and didn't force the price of cigarettes up to a level that is literally prohibitive, none of this would happen. And maybe you shouldn't have banned e-cigarettes too, eh?

 

Minister for Home Affairs Karen Andrews said the federal government remained committed to stopping the illegal trade at the border.

“Every time someone uses illicit tobacco, they’re denying the community legitimate tax revenue that funds our schools, hospitals, and roads,” she said. 

 

It's not legitimate tax revenue though, is it Karen? It's extortion. Your government has set it at such a punitive rate that many smokers have no choice but to buy illicit and none of them have a moral duty to send more money to a government that openly despises them. 

"They’re also playing into the hands of serious and organised criminals, who often import illicit tobacco and sell it to fund importations of harder drugs."

 

Maybe so, but you were warned about this plenty of times and you preferred to listen to unscrupulous shysters from 'public health' waving around worthless studies claiming that tax rises don't fuel the illicit trade.

 

Good luck with your new drug war. 

 

See here and here for more examples of Australia's self-inflicted wound.

Vapers deserve to be angry – they are under attack

First published by Spectator Health in June 2015

There is a perception – on Twitter at least – that vapers are angry and abusive. Ben Goldacre recently described ‘e-cigarette campaigners’ as ‘vile… obsessive, vindictive, abusive, and to an extent that is clearly dubious’. This inevitably led to a string of replies from bewildered vapers that may have confirmed his view, although the vast majority were polite.

From what I’ve seen, vapers are no more likely to be offensive than any other punter on social media, which is admittedly a low bar. After the referendum on Scottish independence and the general election, not to mention the periodic bursts of outrage for which Twitter is notorious, I have seen much worse in recent months than a few e-cigarette users complaining about junk science and needless, destructive legislation. If the people who disagree with ‘austerity’, for example, or with the opinions of Laurie Penny, expressed themselves in the same way, Twitter would be a more courteous and eloquent place.

That is not to say that vapers are not angry but, as this week’s announcement of a ban on vaping in Wales shows, they have just cause. Banning vaping indoors is such a criminally stupid and negligent idea that even the prohibitionists at Action on Smoking and Health are opposed to it. The unintended consequences are utterly predictable. Once people who have switched from smoking to vaping are thrown outside, they may come to the conclusion that they might as well smoke. Meanwhile, smokers who might switch to vaping have one less incentive to do so. The negative effect on health is plain to see, even if we ignore the glaring fact that none of this is the government’s business.

Vapers have every right to be outraged by this evidence-free attack on a habit that is not only harmless to bystanders but positively beneficial to them personally as erstwhile smokers. This is the important point to remember about so-called ‘e-cigarette campaigners’. They used to be smokers. You know how some ex-smokers can seem a little self-righteous and pleased with themselves? Vapers have taken that sense of triumph and channelled it into promoting – or, at least, protecting – the product that helped them quit.

As smokers, vapers spent years being taxed, demonised and kicked into the street. Anti-smoking campaigners would never put it in such blunt terms, but their objective is to make smokers’ lives so miserable that they decide to quit smoking. Vapers did quit smoking, often to their own surprise. They did exactly what was asked of them, but instead of being embraced by their old tormentors, they found themselves with another battle to fight.

The last few years have seen an extraordinarily dishonest campaign of misinformation against e-cigarettes that is as bad as anything I have seen from the ‘public health’ lobby. There has been a concerted effort to portray e-cigarettes as a ‘gateway’ to tobacco, despite all the evidence showing that they are a gateway from tobacco. They have been accused of ‘renormalising’ smoking without a scintilla of evidence. Misleading research has led to numerous unfounded scare stories in the press. Newspaper columnists have written ridiculous articles without doing the most basic fact-checking. Senior medics have explicitly told the public that e-cigarettes are no safer than real cigarettes. At the same time, ordinary vapers who never had any intention of becoming campaigners – and, indeed, are not campaigners – have been accused of being shills for e-cigarette and/or tobacco companies for doing no more than trying to put the record straight.

The irony is that if vapers on social media were part of an ‘astro-turf’ campaign for industry, they would not speak out as bluntly as they do. The ‘public health’ lobby is quite comfortable dealing with the pitched battles that come from having a polite, professional and organised opposition. It is the public they can’t handle.

Stanton Glantz, an activist-academic at UCSF says that he receives ‘hyper-aggressive’ responses whenever he posts a blog about e-cigarettes while Martin McKee, a professor of public health, says: ‘Anyone who suggests e-cigarettes are anything short of miraculous seems to be targeted’. This is a little disingenuous. Glantz and McKee have done rather more than suggest that e-cigarettes are not miraculous. McKee wants e-cigarettes to be regulated as if they were medicines while Glantz has helped bring about the banning of not only the use, but also the possession, of e-cigarettes on his campus in San Francisco.

These are people who have the power to turn their thoughts into deeds. They do not need to attack e-cigarette users verbally, though some do. Last year, the president of the UK Faculty of Public Health was suspended after a late-night Twitter binge in which he used such colourful phrases as ‘obsessive compulsive abusive onanist,’ ‘slave to addiction’ and ‘c***’ to describe e-cigarette users. He was later reinstated and the UK Faculty of Public Health is loudly supporting the Welsh vaping ban in the media this week.

If vapers are frustrated, it is because they are the helpless against the powerful. Combine the sense of righteousness that comes from being an ex-smoker with the sense of injustice that comes from hearing endless lies about something that is dear to you, you have a recipe for righteous indignation. There will be a lot of it around this week, quite justifiably.

A swift half with Kristian Niemietz

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

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'.

Have a listen.

A new Swift Half with Snowdon will be coming soon.

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.

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’.

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?