The Academy of Medical Royal Colleges obesity initiative – my submission
Back in April 2012, The Academy of Medical Royal Colleges announced that they were launching a review into the UK “obesity crisis”. The initiative was launched in a front page article in The Observer 15th April 2012. The idea was that the body that represents 220,000 doctors in the UK would seek evidence from any individual or organisation that wished to contribute to the debate. An excellent initiative. A great opportunity and, having seen a copy of the report in preparation for media interviews tomorrow, tragically, a completely failed chance to do something that really could make a difference to the obesity epidemic.
Below is my full submission to the steering group…
The Obesity Epidemic
“The previous nutritional advice in the UK to limit the intake of all carbohydrates as a means of weight control now runs counter to current thinking and contrary to the present proposals for a nutrition education policy for the population as a whole… The problem then becomes one of achieving both a reduction in fat intake to 30% of total energy and a fall in saturated fatty acid intake to 10%.”[i]
Proposals for nutritional guidelines for Health Education in Britain (1983)
And so started the obesity epidemic…
In a study of formerly obese people, researchers at the University of Florida found that virtually all said that they would rather be blind, deaf or have a leg amputated than be obese again.[ii] That is the extent of our desire to be slim and yet two thirds of people in the UK, USA and Australia are overweight and one quarter obese. Why?
To be slim, to achieve the thing we want more than our sight, hearing, or mobility, we are told that we just need to “eat less and/or do more.” Quite specifically, the advice is “One pound of fat contains 3,500 calories, so to lose 1lb a week you need a deficit of 500 calories a day.”[iii]
So, why don’t we follow the advice? Why do we have an obesity problem, let alone an epidemic, when we so desperately want to be slim?
I set out to answer that question in the late 1980’s and this submission is a summary of my findings. In 1972, World Health Organisation statistics recorded 2.7% of UK men and women as obese. Fewer than three decades later, in 1999, the same statistics found 22.6% of men and 25.8% of women were obese.[iv] Two thirds of UK citizens are now overweight or obese.
The USA started from a slightly higher base and displayed a virtually identical trend, with 70% of Americans currently overweight or obese.
The starting point for understanding the obesity epidemic must be: what changed in the late 1970’s/early 1980’s? Was there one occurrence that could explain the sudden and dramatic increase in obesity?
Yes there was. In 1977 the USA changed its public health diet advice. In 1983 the UK followed suit. A more accurate description would be that we did a U-turn in our diet advice from “Farinaceous and vegetable foods are fattening, and saccharine matters are especially so”[v] to “base your meals on starchy foods”. Obesity has increased up to ten fold since – coincidence or cause?
We changed our advice for the wrong reason. We changed it to the wrong advice.
In the 1970’s, the fact that (fewer than six) people (in one thousand) were dying from heart disease was of great concern to America. American public health advisors wanted a solution. Ancel Keys had spent the 1950’s trying to prove that cholesterol consumption was the cause of heart disease. He failed and he acknowledged this. He then tried to prove that saturated fat consumption causes heart disease, despite this having no logic, not least because saturated fat and cholesterol (and unsaturated fat) are found in the same foods. At the time that Senator McGovern was looking for the first Dietary Goals for the United States, the Keys theory was not the only idea available for consideration, but it was the best promoted. The rest, as they say, is history.
The USA changed its dietary advice and the UK followed. We told people that fat was bad and carbohydrate was good not because we knew either fat to be bad or carbohydrate to be good. At the time we changed our advice, the only ‘evidence’ for fat being bad was a suggestion that, in seven handpicked countries, heart disease tended to be related to cholesterol levels, which tended to be related to saturated fat intake and so (that must mean) heart disease tended to be related to saturated fat, (although cholesterol intake was not directly related per se). Association was never proven and causation was never alleged. We had no evidence that carbohydrate was good – just the admission that, if we tell people not to eat fat they must eat something and “it was advised that starchy carbohydrates should replace the reduction in fat as an energy source.”[vi]
We have not looked for proof since:
– “There has been no controlled clinical trial of the effect of decreasing dietary intake of saturated fatty acids on the incidence of coronary heart disease nor is it likely that such a trial will be undertaken.” (COMA, 1984).[vii]
– “It has been accepted by experienced coronary disease researchers that the perfect controlled dietary trial for prevention of coronary heart disease has not yet been done and we are unlikely ever to see it done.” (Truswell, 1994).[viii]
– “The ideal controlled dietary trial for prevention of heart disease has not yet been done and it is unlikely ever to be done.” (FSA, 2009).[ix]
The ultimate irony is that if Keys did show anything, he showed a relationship between the 100% carbohydrate, sucrose, and heart disease: “The fact that the incidence of coronary heart disease was significantly correlated with the average percentage of calories from sucrose in the diets is explained by the inter correlation of sucrose with saturated fat.”[x] Decades later we have not corrected this fundamental mistake and we still list biscuits, cakes and pastries – carbohydrates first and invariably unsaturated fat second – as saturated fats. We changed our advice to try to alleviate heart disease and, as a result of this catastrophic confusion over macronutrients, our citizens are consuming more of the foods that should have been clearly identified as the culprits in the first place.
We have forgotten that we eat for nourishment. We have a vital need for nutrition and we have lost this basic value in our current dietary advice. If we had stayed true to the principle of why we eat, the most nutritious foods would be evidential in any analysis of fat, protein, vitamins and minerals. They are the liver, sardines, milk, eggs and greens favoured by our elders and not the fortified cereals and margarines favoured by conglomerates and, reprehensibly, far too many dietary advisors alongside.
An industry originated marketing campaign, five-a-day, has become the leading public health message in tens of countries across three continents and it is spoken of as if there is overwhelming evidence behind it, when the reality is that there is none. Worse, if the proponents of pick-a-number-a-day knew what Dr Richard Johnson[xi] and Dr Robert Lustig[xii] know, they would surely revise their opinion of fructose and never mention fruit juice again.
We have slandered and libelled the most nutritious macronutrient – fat and we have promoted and praised the least nutritious macronutrient – carbohydrate. We don’t need to look far to understand why. The most nutritious foods on the planet are those provided by nature, naturally rich in protein and fat. The most profitable foods on the planet are those provided by food manufacturers, UNnaturally abundant in sugar, flour and vegetable oils.
As the demonisation of real food has gathered pace, fledgling and long standing food and drink companies have become multi-billion dollar empires. “The world’s largest convenient food and beverage company”, PepsiCo, is bigger than 60% of the countries in the world.[xiii] An immense and profitable industry has grown on the back of the low fat, high carbohydrate advice that we invented. Human beings have become high fat and low health in parallel.
When people talk about “the obesogenic environment”, they do so as if this were some inexplicable phenomenon that crept up on the world and made everyone fat. We created this obesogenic environment; it did not happen to us. We told people to avoid real food and to eat processed food. We passed legislation to introduce trans fats and sweeteners into our food chain. We allowed our children to be given toys, cartoon characters and junk food by ‘strangers’.[xiv] We have facilitated the comprehensive infiltration of the food and drink industry into our dietary advice – nowhere more so than in the fattest nation on earth, America, where we have gone as far as legislating the relationship, so that only the food industry sponsored American Dietetic Association can advise the unsuspecting public. We put cakes, cola and sweets on government posters, pyramids and plates of role model healthy eating. We welcomed food and drink industry funds turning global sporting events into advertising arenas for their products. We continue to revere sports and pop stars, who are paid millions of dollars to endorse products that they likely don’t consume themselves. We care more about the profitability of Kellogg’s and McDonald’s than we do the health of our citizens. Prove me wrong governments and take decisive and immediate action. Just don’t act like this environment is nothing to do with you.
Had we changed our advice for the wrong reasons and to the wrong advice without consequence, we would have been fortunate. We have not been fortunate. We have paid an enormous price for this change; with a tenfold increase in obesity. Furthermore, more people are continuing to become obese and the obese are continuing to become more obese and we have not yet had the first generation born to our most obese generation. It is not unreasonable to say that on the back of one man’s study, first adopted by one American Governor and then the world, we have an obesity epidemic.
As obesity doubled for UK adults between 1972 and 1982 and then almost doubled again by 1989 and then almost another time by 1999, the urgency and desperation to lose weight was palpable. The advice that people were given was the same as the advice that made them overweight in the first place: eat less fat – eat more carbohydrate; eat less real food – eat more processed food.
Eat less/do more became such a common mantra that we stopped looking for the real solution to obesity; despite the fact that we had evidence going back to 1917 that eat less/do more does not work.[xv] The level of failure was quantified in 1959 by Stunkard and McLaren-Hume at 98%.[xvi] Another irony could be that we ignored the brilliant and unbiased study done by Ancel Keys and favoured instead the one where he set out to prove an already held view. Keys did the definitive study to show exactly what happens when we manage to restrict calorie intake and that even this can only be achieved ‘in captivity’, due to the hunger that ensues. We know from The Minnesota Starvation experiment that calorie restriction results in a disproportionate reduction in energy expenditure and metabolic activity and that the ‘circular reference’ will defeat the dieter in weeks.[xvii]
As we tried to fix a crisis, without making the connection that we started it, we compounded the challenge by proceeding on the basis of flawed assumptions – theoretical and empirical.
The theoretical error we made was to simplify the application of the laws of the universe to the world of dieting – we got the first law wrong and ignored the second law. If we had considered both properly, we would have realised that obesity is not a simplistic outcome of energy in (overweight people eat too much) and/or energy out (overweight people are too sedentary). We would have realised that energy in can only equal energy out if the body makes no internal adjustment whatsoever. Not only is this biochemically impossible, the internal adjustment made by the body, in response to changes in energy intake and/or energy requirements, is likely far greater than any change in fat reserves that the body can or will make.
Empirically, we got hold of a calorie formula, we know not from where, which we hold to be true and continually prove to be untrue. One pound does not equal 3,500 calories. We will not lose one pound if we create a deficit of 3,500 calories. The most fundamental tenet of the diet world fails basic scrutiny. Worse, seven public and obesity health authorities (Department of Health, NHS, British Dietetic Association, Dieticians in Obesity Management, Association for the Study of Obesity, National Obesity Forum and National Institute for Clinical Excellence) all failed to prove their formula and none knew from whence it came. If we carried on teaching children that London is the capital of America, when we knew this to be wrong, there would be uproar. Yet when the hopes of 1.5 billion overweight people depend upon an equally wrong, but vastly more serious, untruth, we continue to lie.
We know that any answer to the obesity epidemic must explain what has changed since circa 1980. The answer, therefore, can not be found in something we have been eating for over one hundred thousand years (real food – especially fat). The answer can not be found in anything we have been eating less of during the past thirty years (real food – especially fat). The answer can be found in anything we have not been eating for over one hundred thousand years (processed food – especially carbohydrate). The answer can be found in anything we have been eating more of during the past thirty years (processed food – especially carbohydrate).
The answer similarly can not be found in the other half of the energy in equals energy out oversimplification. Sedentary behaviour did not cause the obesity epidemic. Exercise will not cure it. The conclusion of the one study that tried to quantify the contribution played by energy intake vs. energy expenditure (Swinburn) was that Americans had been expending more energy during the period in which the average person gained 20 pounds.[xviii] The Department of Health document At least five a week admits that the evidence for the benefits of exercise for preventing or treating obesity is not in abundance and not strong. [xix]
We opened with Colleen Rand’s brilliant study of how much people would rather be something else than obese. The precise numbers were that 100% of those researched would rather be deaf, 89% would rather be blind and 91% would rather have a leg amputated – than be obese. Proposed solutions are that we surgically impair the stomachs, of our fellow humans. The suggestion that we might return to eating the way that we did, before we needed to invent such drastic procedures, is instead seen as radical.
The decision made by humans to move away from the diet that we have evolved to eat has led to two thirds of the ‘evolved’ world being overweight and a number wishing that they were literally anything else, rather than obese.
As Barry Groves observed: “Man is the only chronically sick animal on the planet.”[xx]
That’s because man is the only species clever enough to make his own food and the only one stupid enough to eat it.
How many more obese humans do we plan to produce before we stop feeding them man-made food? Will the man-made obese ever forgive us for what we have already done? Will we ever forgive ourselves if we make any more? Is it really so preposterous to suggest that we simply return to eating the real food that our planet provides for us? The real food that we used to eat, before we got so fat we’d rather be blind.
[i] The National Advisory Committee on Nutrition Education (NACNE), “Discussion Paper on Proposals for Nutritional Guidelines for Health Education in Britain”, (1983).
[ii] Colleen S.W. Rand and Alex M. C. Macgregor, “Successful weight loss following obesity surgery and the perceived liability of morbid obesity”, International Journal of Obesity, (1991).
[iii] British Dietetic Association’s leaflet “Want to lose weight & keep it off…?”
[iv] https://apps.who.int/infobase/Indicators.aspx. Wadsworth M, Kuh D, Richards M, Hardy R, The 1946 National birth cohort (MRC national Survey of Health and development).
[v] Thomas Hawkes Tanner, The Practice of Medicine, (p217), (1869).
[vi] Letter from the FSA to Zoë Harcombe, (25 September 2009).
[vii] Committee on Medical Aspects of Food Policy, “Diet and Cardiovascular Disease: Report of the Panel on Diet in Relation to Cardiovascular Disease”, (1984).
[viii] A Stewart Truswell, “Review of dietary intervention studies: effect on coronary events and on total mortality”, Australian New Zealand Journal of Medicine, (1994).
[ix] Letter from the FSA to Zoë Harcombe, (25 September 2009).
[x] Robert H. Lustig, “The Fructose Epidemic”, The Bariatrician, (June 2009).
[xi] Richard J Johnson, Mark S Segal, Yuri Sautin, Takahiko Nakagawa, Daniel I Feig, Duk-Hee Kang, Michael S Gersch, Steven Benner and Laura G Sánchez-Lozada, “Potential role of sugar (fructose) in the epidemic of hypertension, obesity and the metabolic syndrome, diabetes, kidney disease, and cardiovascular disease”, The American Journal of Clinical Nutrition, (October 2007).
[xii] Robert H. Lustig, Laura A. Schmidt & Claire D. Brindis, “The toxic truth about sugar” Nature, (February 2012).
[xiii] http://www.fortune500s.net/pep.php http://en.wikipedia.org/wiki/List_of_countries_by_GDP_%28nominal%29#cite_note-0
[xiv] The Centre for Science in the Public Interest calls McDonald’s “The stranger in the playground”.
[xv] Francis G. Benedict, Human Vitality and efficiency under prolonged restricted diet, (study 1917, published 1919).
[xvi] Albert Stunkard and Mavis McLaren-Hume, “The results of treatment for obesity: a review of the literature and report of a series”, Archives of Internal Medicine, (1959).
[xvii] Ancel Keys, The Biology of Human Starvation, Minnesota University Press, (1950).
[xviii] Swinburn B., “Increased energy intake alone virtually explains all the increase in body weight in the United States from the 1970s to the 2000s”, 2009 European Congress on Obesity, Abstract T1:RS3.3, (May 6-9, 2009).
[xix] Department of Health, At least five a week, (April 2004).
[xx] Barry Groves’ presentation at the Weston Price Foundation European conference, London, (21 March 2010).