Aseem contacted me recently and we met up in London and his energy and determination to do something about obesity is inspirational. He is very sensibly focussing on childhood obesity as the starting point. Let’s get some foundations in place to help the next generation and then we can address the horrific state of many of our adult citizens.

Aseem has networked a ‘coalition of the willing’ – people who want to make a difference to the weight of our nation – from Jamie Oliver to Dr David Haslam, Chair of The National Obesity Forum, to Christine Blower, the General Secretary of the National Union of Teachers, to Charlie Powell, Director of The Children’s Food Campaign and more. Professor Terence Stephenson, President of the Royal College of Paediatrics and Child Health, was a crucial signatory. Professor Stephenson recently launched an initiative on behalf of the Academy of Medical Royal Colleges seeking evidence for our current obesity strategy. I was delighted to be asked to put my name to the letter, which was sent to Prime Minister David Cameron, at the weekend.

Aseem is also a member of Professor Stephenson’s obesity steering group and wrote a supporting article in The Observer on the day that the Royal Colleges’ initiative was announced. The medical profession is starting to ‘join up’ in a way that the government needs to emulate.

The letter to David Cameron initiated and written by Aseem called for “Food education and cooking skills”.  This is not about learning how to cook pizza, pasta and cheesecake (as my 16 year old step son has learned in his GCSE in Nutrition!), but about teaching children about nutrients and where they will find essential fats, complete protein, vitamins and minerals. No surprise – these will be found in the real food provided by our planet and not the fake food provided by food manufacturers.

Aseem managed to get Steven Gerrard on board – and the first team doctor for the Liverpool football team – Dr Zafar Iqbal. Great to have elite athletes and their medical staff endorsing a positive message rather than the Mars, Cadbury, Coca-Cola, McDonalds tragically so often associated with sport.

The BBC headlined the story throughout Sunday and Assem’s day was long – starting with an appearance on BBC breakfast at 6.15am! Footage of children learning how to prepare and stir fry meat and vegetables provided a great backdrop to the sensible comments being presented. Steve Iredale, President of the National Association of Head teachers, was equally impressive in his pre-recorded interview. He was another signatory and a welcome one given the facts that Aseem presented about 71% of packed lunches containing fizzy drinks, crisps, confectionery bars and other items that will only make childhood obesity worse.

Aseem had recently written in the Observer about his visit to a primary school in Southwark, (Britain’s child obesity capital) where he was invited to speak to kids about healthy eating by a very proactive teacher who had herself taken things into her own hands to stop kids eating junk food in school. The article received much interest and was tweeted by Jamie Oliver to over 2 million of his followers worldwide.

Yesterday’s story was covered extensively throughout the day:

BBC: Steven Gerrard & Jamie Oliver call on PM to fight obesity.

ITN: Jamie Oliver and Steven Gerrard unite for obesity campaign. 

Sky News: Stars cook up lesson plan to fight obesity.

The Telegraph: Jamie Oliver: Government should introduce cookery lessons in schools.

The Guardian: Steve Gerrard joins call for school cookery lessons to fight obesity.

The Week: Steven Gerrard: so worried about obesity he writes to the PM.

And many more.

The Huffington Post also covered the story and used one of my quotes from the press release.

As Aseem said on the breakfast TV sofa – this is just the first step. Many more initiatives will be needed. Given the energy and drive of the people who signed that letter, I have no doubt that a momentum has been started that will not stop until we start to make a difference!

The Press Release

Jamie Oliver, senior NHS figures and teaching union leaders are urging David Cameron to make learning to cook compulsory for school pupils in a bid to tackle soaring levels of childhood obesity

In a letter to the Prime Minister leading professionals in the field of medicine, food, sport, education and cookery call on the Department for Education to introduce a minimum of 24 hrs practical cooking skills and food education for all pupils at each of the first three key stages (ages 4-14) into the national curriculum.

The group believe that this is an important step which will help tackle the rising epidemic of obesity with related diseases costing the NHS £5 billion per year.

Research shows that practical cooking skills learned in school enable individuals to prepare nutritious meals for themselves and their families. Not having these skills means people are less likely to exercise meaningful control over their diet and food intake and tend to rely on pre-prepared or take away foods.

Although there is proof that legislation has improved the nutritional and health values of school food, this has been undermined by unregulated packed lunches, which make up approximately 60% of all pupils lunches. Recent research by the school food trust has demonstrated up to 71% containing food items such as crisps, chocolates and fizzy drinks.

The letter acknowledges the pride of hosting the Olympic games has been tainted by the shameful fact that Britain is officially the fattest nation in Europe and need for more sporting role models to promote the benefits of a healthy lifestyle to children.

Steven Gerrard has been proactive as an ambassador for the Zesh Rehman Foundation working closely with the Liverpool FC first team doctor to promote the benefits of increased physical activity and healthy eating to children in schools, especially in areas with high social and economic deprivation.

Professor Terence Stephenson, President of The Royal College of Paediatrics and Child Health said:

“The UK now has the highest rate of obesity in Europe with one in three children overweight or obese by the age of 9. If these lifestyles don’t change, the UK will have an adult population suffering with diabetes, heart disease and high blood pressure, giving an already cash strapped NHS a £10 billion a year medical bill.

“We need to act now but we will not win this fight alone. Parents, schools, healthcare professionals and the government must take a united approach in order to combat this obesity crisis.”

Professor David Haslam, Chair of The National Obesity Forum said:

“The 2012 Olympics provide a unique opportunity to improve the nation’s health, and reduce the burden of obesity which leads to diabetes, heart disease, cancer and other conditions; and ultimately premature death. However sitting in front of the television, cheering our elite athletes on, whilst eating crisps and chocolates, drinking sugar sweetened beverages is entirely counterproductive. National enthusiasm must be accompanied by an improved diet and enhanced physical activity by the entire population, not just by our Olympians, for a significant difference to be made to the deteriorating health of the population.”

Charlie Powell, Director of The Children’s Food Campaign said:

“Cooking is a vital skill for life. Without it how can children put into practice what they know about good food? It’s common sense that all children should learn how to cook at school, so it should be part of the National Curriculum. If the government is serious about improving children’s health, keeping cooking in schools is one of the best ways to do it.”

Zoë Harcombe, Author and obesity researcher said:

“Nutritional education must be an integral part of this initiative: where are essential fats? complete proteins? vitamins and minerals? Why are they so vital for our health? What will we suffer without them? To reverse the obesity epidemic we need our fellow humans to be able to source and prepare real food, not to microwave fake food. Food education and cooking skills were traditionally passed down from one generation to the next. We seek the Prime Minister’s help to restore them in our future generation.”

All media enquiries to Dr Aseem Malhotra, Cardiology Specialist Registrar, London

List of signatories:

Dr Aseem Malhotra, Cardiology Specialist Registrar and then in alphabetical order:

Sir William Atkinson KBE, Executive Head teacher, The Phoenix Canberra Schools Federation

Christine Blower General Secretary, National Union of Teachers

Professor Simon Capewell, Chair, Clinical Epidemiology Department of Public Health & Policy, University of Liverpool

Dr Peter Carter, Chief Executive & General Secretary, Royal College of Nursing

Tam Fry, Honorary Chairman, Child Growth Foundation

Zoë Harcombe, Author & obesity researcher

Professor David Haslam, Chair, National Obesity Forum

Dr Clare Gerada, Chair, Royal College of General Practitioners

Steven Gerrard, Captain, Liverpool FC, England International, Ambassador for ‘Get Up, Get Moving’ ZRF Project

Dr Zafar Iqbal, First Team Doctor, Liverpool FC, Health Advisor, ZRF

Steve Iredale, President, National Association of Head Teachers

Tim Lang, PhD, Professor of Food Policy, Centre for Food Policy, City University

Paul Lincoln, Chief Executive, National Heart Forum

Jamie Oliver MBE

Charlie Powell, Director, Children’s Food Campaign

Rob Rees, Chairman, Children’s Food Trust

Professor Terence Stephenson, President, Royal College of Paediatrics and Child Health

Professor John Wass, Professor of Endocrinology, Oxford University

Described as “Why should we eat five a day? And is butter bad? A food writer explores the science and explains why…” the article is supposed to be evidence based and scientific. I tweeted that there is more food science in a packet of cornflakes than in this article. It does, however, serve as a great example of how we must question everything and assume nothing.

Are apples really good for me?

Is the first question asked by Hattie Ellis. She opens by noting that the phrase “’an apple a day keeps the doctor away’ was originally a marketing slogan dreamt up by American apple growers at the start of the 20^th century.” This should have raised alarm bells immediately to suggest that it was not based on scientific evidence. However, Ellis seems to have no such worries and post rationalises the value of apples, notwithstanding the origin of the slogan.

“Apples are a good source of fibre” is the first justification for eating apples. Ellis distinguishes between insoluble and soluble fibre. The latter, she claims, can lower cholesterol. She assumes that this is a good thing. I suggest quite the opposite. This blog can explain why cholesterol is a good thing per se and lowering cholesterol is anything but.

The following passage from Dr Uffe Ravnskov, a world expert on cholesterol, explains why having plant sterols compete in the gut for the human cholesterol made by the body is not a good idea:

“It is questionable if a lowering of cholesterol by dietary means is equivalent with a lowering of the risk of coronary heart disease (CHD) because hitherto no unifactorial dietary trial has succeeded in lowering cardiovascular or total mortality.^1,2 What the authors also ignore is that an increased intake of plant sterols is associated with an increased cardiovascular risk. In at least four cohort studies a high intake or a high plasma level of plant sterols were independently associated with a higher risk of CHD, and in experiments on mice a dietary supplementation with plant sterol esters equivalent to a commercial spread induced endothelial dysfunction.³ “ (References at the end)

Ellis also unquestioningly accepts “The Department of Health recommends that adults consume 18g of fibre per day”. Why? Notice on the NHS page about “Why is fibre important?” that the page opens with “Fibre is a very important part of our diet…” but makes no attempt to explain why. Why fibre per se? Why 18g of fibre per day? Where is the study that showed any benefit for fibre, let alone the precise number of 18g per day? Where is any evidence? There is none. Instead Ellis just accepts this nutritional myth and proceeds on the basis that fibre is good and apples provide fibre so apples are good. (A former Cambridge University peer of mine is now a UK bowel specialist and he prescribes as little fibre as possible in the diet.)

Ellis suggests a benefit that the NHS page doesn’t – “by hitting the daily recommended fibre intake we may be lowering our risk of colorectal cancer. While diets containing more than 80g of meat per day have been linked to a higher incidence of these tumours, a fibre-rich diet seems to cancel out this effect.” This is all very vague and suggestive and makes the usual error of confusing association with causation. Here is my more scientific take on the red meat and bowel cancer study. There is no mention in this SACN (Scientific Advisory Committee on Nutrition) study of a fibre-rich diet “cancelling out this effect”, let alone apples having anything to do with anything.

We then leap from apples to cider vinegar – more cholesterol lowering claims are made; more assumptions that the utterly life vital substance that is cholesterol is bad; more confusion between association and causation.

The only vitamin mentioned in the “apples are good” section is vitamin C – which is, of course, the only one of the 13 vitamins and c. 16 minerals for which apples are a decent source. In the red meat criticism, Ellis neglected to mention that liver has nearly four times the vitamin C content of an apple – but then not many people know that.

What is the best breakfast?

This section starts with a half hearted attack on sugary cereals – great in principle, weak in execution. Low GI cereals end up being the first recommended breakfast.

“Go to work on an egg” starts the next suggestion, which lifted my heart thinking that we would get an excellent egg breakfast suggestion. Instead Ellis recommends poached egg on glucose (sorry – wholegrain toast) and suggests that the full English breakfast “will keep you full for a long time. However, the calories can be alarmingly high”. Not if you avoid the carbohydrates, which no real food fan would consume as part of a healthy breakfast.

Ellis mentions that the full English breakfast contains protein and fat and that is all that it need contain. Bacon and eggs, without the sugary baked beans and starchy bread, is an excellent source of fat, protein, (including the essential fats and complete range of amino acids), vitamins and minerals. Add a tomato (a bit of carb) and it really does provide the full range of nutrients. Two rashers of bacon, two eggs and a tomato adds up to just under 300 calories – infinitely more nutritious and filling than the cereal that would likely provide more. Far more important than the calories is the very low carb content, which will keep blood glucose stable and protect against diabetes and obesity.

Ellis does rightly correct the British Dietetic Association advice to have a glass of freshly squeezed orange juice, which would give a massive shot of sugar (fructose and glucose) into the body to upset blood glucose levels from the start of the day. Ellis advises that the whole fruit would be better. If one must eat fruit, this is correct, but meat/fish/eggs/veg & salad will always be better than fruit.

Can I eat to avoid heart disease and cancer?

This section jumps all over the place and sadly not from fact to fact:

1) “Eating too many calories can lead to you becoming overweight, which raises risk of heart disease and cancer.” Wrong. I have written 135,000 words on this topic “The Obesity Epidemic: What caused it? How can we stop it?” The evidence supports the fact that carbohydrates – which we have been instructed to ensure form 55-60% of our dietary intake – are together responsible for obesity, heart disease and cancer (and diabetes, Alzheimers and all modern illness). Obesity is not a cause of heart disease and cancer – it is another condition alongside, caused by our appalling diet. (Additionally smoking, lack of activity, stress and many other causal factors apply in the case of heart disease and chemicals, sugar, pollution etc are key causal factors for cancer.)

2) Ellis then quotes Walter Willett of Harvard Medical School who openly declared war on red meat some time ago – giving me the opportunity to expose the bias and lack of science in the Harvard studies – Part 1 and Part 2.

Whole grains are promoted instead, as Ellis quotes Willett: “They provide fibre and micronutrients such as folic acid, magnesium and vitamin E”. Fibre we’ve already established has no evidence base (and we should investigate the rise in bowel disease, from IBS to cancer, which has accompanied our rise in fibre intake). The evidence confirms that liver has over 13 times the folic acid of whole wheat flour and that’s gram for gram. Given that liver has approximately one third of the calories of whole wheat flour, calorie for calorie, liver has nearer 40 times the folic acid. Cocoa powder has nearly four times the magnesium of the same flour, gram for gram, and again is substantially lower in calories. Sardines have two and a half times the vitamin E for a fraction of the calories. Better still, sunflower seeds are the ultimate vitamin E super food – with 42 times the vitamin E content of the flour – albeit for just over one and a half times the calories. We rave about whole grains and then try to justify telling people to consume them. If we really were trying to explore the food science, with evidence, the facts would speak for themselves.

3) Ellis then quotes Professor Corder from Barts on red wine – why quote random different people on random different foods and drink? Ellis is the food science writer – how would she answer the question heading up this section: Can I eat to avoid heart disease and cancer?

My answer would be “You cannot guarantee avoidance of any illness, but you can minimise your chances of heart disease by eating naturally farmed meat/fish/eggs/dairy products/vegetables/salads and seeds and minimising your carbohydrate intake to ensure weight and blood glucose level control. Additionally don’t smoke, moderate your stress and do something active that you enjoy each day. To minimise your risk of cancer, which is a modern illness, minimise your exposure to modern life. The diet advice is the same, but particularly avoid sugar (sucrose) like the plague. Let not one grain pass your lips if you really want to minimise your risk of cancer. Additionally minimise exposure to chemicals, toiletries, pollution and other modern unnatural substances.”

How should I eat my five a day?

This is completely the wrong question! A food science writer doing an investigative article should ask – why five a day? Not how should I eat my five a day?! She would then find, as I did when I asked this question, that it originated in the same way as the “apple a day keeps the doctor away” nonsense. It was “dreamt up” by the fruit and veg companies in 1991 to sell more fruit and veg. Here are the facts on this nutritional myth Even worse is that Ellis heads in this direction but gets it wrong and writes that five a day was created by a state nutritionist in 1998. Even knowing this, the alarm bells should have been ringing again and warning that this is a nutritional myth and not an evidence based nutritional message.

The 2011 study in the European Heart Journal is quoted. Here is the level of analysis that Ellis should have done before accepting this as fact. This blog post takes the origin of the data used by the 2011 study (the European Prospective Investigation into Cancer study) and what the EPIC study concluded about fruit and veg consumption and what the heart team then did to try to find a positive benefit for fruit and veg. As Einstein said – if you know what you’re looking for, it’s not research!

We at last have two statements with which I would agree – 1) eat vegetables rather than fruit because they have more micronutrients and less sugar and 2) vitamin C is destroyed in cooking – so try to eat your vegetables raw or lightly steamed.

The closing line is close to common sense, but it still doesn’t get to the heart of the matter – the fat soluble vitamins in vegetables are only of use to the body if delivered in/with fat. However, an even better way to get the fat soluble vitamins, A, D, E and K is to eat the meat/fish/eggs and dairy foods in which they are abundant. Additionally retinol (the form in which the body requires vitamin A), D3 and K2 are only found in animal foods, not vegetables.

This is not a scientific article and there is little evidence of investigation and questioning undertaken to make it so. This is not intended as a personal attack on the author who is likely a very decent person with good intentions. However, the world is full of nutritional fairy stories that desperately need exposing for the health and weight of our fellow humans. It is bad enough seeing yet another article perpetuating the myths, rather than exposing them. It is even worse when the article claims to be doing the exact opposite.

(p.s. On the same day that this article was published “The Sun on Sunday” reported: “A third of kids believe that eating an apple a day means they will never have to see a doctor, a poll found.” That’s how serious bad science is).

References for the Uffe Ravnskov extract:

1.  Ravnskov U. The questionable role of saturated and polyunsaturated fatty acids in cardiovascular disease. J Clin Epidemiol. 1998;51(6):443-460.

2.  Hooper L, Summerbell CD, Higgins JP et al. Dietary fat intake and prevention of cardiovascular disease: systematic review. BMJ. 2001;322(7289):757-763.

3.  Weingärtner O, Böhm M, Laufs U. Controversial role of plant sterol esters in the management of hypercholesterolaemia. Eur Heart J. 2009;30(4):404-409.

On March 20, I emailed the author listed for personal correspondence (frank.hu@channing.harvard.edu) with the following query:

Dear Dr Hu
Please can you help me understand how the multivariate analysis was done in your study (http://archinte.ama-assn.org/cgi/content/full/archinternmed.2011.2287)?

The raw data in table 1 shows the death rate falling – with Q2 and Q3 lower than Q1 in the HPFS and Q2, Q3 and Q4 lower than Q1 in the NHS. This is while exercise is falling and BMI, diabetes, smoking, calorie & alcohol intake were all increasing alongside red and processed meat consumption. I would have thought that once your multivariate analysis had allowed for these (and many other) variables to try to isolate meat consumption, the multivariate index would be substantially lower than my death rate line, which includes these risk factors. As a comparison, if I index my death rate for the HPFS is would be 1.00; 93.43; 97.70; 103.97 and 124.26 (doing the same 1.00 base line thing) vs. the multivariate index of 1.00; 1.12; 1.21; 1.25 and 1.37.

Many thanks
Kind regards – Zoe

—————

I received  a prompt reply later that day:

Zoe,

Frank Hu

—————

I emailed back on 22 March:

Many thanks for the prompt reply. Aside from thinking that “Age is the main risk factor in mortality” would have been a better headline, I’m still puzzled. Please can you help with the following:

1) Table 1 says it is age standardised – what does this mean? (*)

2) The ages in Table 1 are 53.8, 52.6, 52.5, 52.5 and 52.2 for Q1 to Q5 respectively for the HPFS and 47.3. 46, 45.8, 45.3 and 46 for the NHS. Not withstanding query 1, how could such small differences have had such an impact on the study a) per se and b) to the extent that “age was a stronger confounding factor than other lifestyle factors” when exercise was down by over a third, BMI up from normal to overweight, smoking almost three times higher in Q5 than Q1, incidence of diabetes almost doubled, alcohol intake up 60% and calorie intake over 40% higher (all figs for the HPFS – the NHS has different numbers, same trends) and that’s even before we look at meat consumption.

3) The death rates that I calculated were from Table 2 – notwithstanding query 1. Hence as total red meat, ‘unprocessed’ red meat (hamburgers?!) and processed red meat all rose from Q1 through to Q5, so the death rates in the HPFS are lower in Q2 and Q3 than Q1 and the death rates in the NHS are lower in Q2, Q3 and Q4 than Q1. Even if Q1 is supposed to be ignored for some strange reason, the Q3 death rate is still lower than Q2 in all meat categories in the NHS and for the ‘unprocessed’ meat category in the HPFS i.e. deaths fall as these groups of meat consumption rise.

4) If I ‘index’ the death rates, as has been done in the multivariate study, the death rate ‘index’ for the HPFS and the NHS are as follows – with the total meat multivariate index alongside. I would expect all the above mentioned factors (reduced activity, increased BMI, increased smoking, increased diabetes, increased alcohol and increased calorie intake from Q1 to Q5) to be impacting death rates so that they also rise from Q1 to Q5. a) they don’t and b) how can the multivariate line have allowed for all of these and yet rise consistently as it does?

Many thanks
Kind regards – Zoe

(*) the reason for asking this question was not because I don’t know what “age standardised” means but to flush out why the reply from Frank Hu was effectively that the data is misleading because of age and yet the table claims to have been age standardised

—————

I received no reply.

On 3 April I resent the unanswered email:

Dear Frank
Please are you able to reply to this?
Many thanks
Kind regards – Zoe

I received no reply.

I’ll update this post with any response that Frank Hu makes.

This is the original article in the Archives of Internal Medicine, entitled “Association Between More Frequent Chocolate Consumption and Lower Body Mass Index“. Was there a press release that claimed chocolate may help keep people slim? Or did the BBC run with that headline and other sheep follow? Whatever happened – the media headlines are some distance apart from the headline of the article, which was reasonably accurate except that the words “Extremely small” should have appeared before the word association.

You will have to pay $30 for the privilege of being able to view the article for one day, so I hope that this saves you some time and money. The article is very short – approximately 1,100 words and with one table. The details are as follows:

Sample

The study involved 1,018 men & women aged 20-85. 68% of these 1,018 people were male and 32% female. However, BMI was only available for 972 subjects and 975 completed a Food Frequency Questionnaire. There is no clarity given as to the number actually used in the study – presumably the overlap between subjects who completed a questionnaire and those for whom BMI was known.

The average (mean) age was 57. The average (mean) BMI was 28 (for 972 subjects) – i.e. overweight. The mean frequency of chocolate consumption was twice a week and the mean frequency of exercise was 3.6 times a week.

Survey

The participants were asked the question: “How many times a week do you consume chocolate?”

Results

Two key statements in the article are:
– “Greater chocolate consumption frequency was linked to lower BMI.”
– “Causality in the observed association cannot be presumed.”

There is no abstract for the article. All you can see on the Archives of Internal Medicine web site without paying for the article is the first 150 words. This is not a useful abstract therefore – one where the headlines of the study and conclusions are presented up front. You cannot tell from the first 150 words what strength of association is being claimed and the article itself makes no claims – it merely makes the “greater chocolate consumption frequency was linked to lower BMI” statement quoted above. May I suggest that this is because the observed association is so insignificant as to be not worth declaring up front in a summary.

We need to look at the only table in the article to see the extent of the association between BMI and frequency of chocolate consumption, as reported by the subjects.

The Beta coefficient (β) is as follows:

For unadjusted data  β = -0.142
Adjusted for age/gender β = -0.126
Adjusted for age/gender/exercise/fat/fruit/veg intake/depression scale & calorie intake! β = -0.208

This is tiny. I appreciate that beta coefficients have been used because the units of the two variables are substantially different (BMI vs frequency of consumption). However, had the Pearson correlation method resulted in a correlation of -0.142 (r=-0.142), the r squared would be 0.02. We would interpret this r squared to mean that 2% of the variability in BMI may be accounted for by frequency of chocolate consumption. This hardly justifies world headlines.

Some comments on the study:

1) The headlines “Chocolate ‘may help people slim’” is not justified by this study. As the article notes – no causation can be presumed – in either direction. Does chocolate help people slim or does being slim help chocolate consumption? The latter is surely a far more logical direction of possible causation. I eat chocolate (85%+ cocoa content) frequently and in large quantities because I am slim. Were I not slim, I would hopefully have the good sense to curtail my chocolate consumption.

2) The article did not seek to find, or therefore find, or therefore claim that there is any relationship between any amount of chocolate consumed and BMI. The only question asked was about frequency of chocolate consumption and the only claim of an observed relationship was about frequency of chocolate consumption.

3) There is no definition of chocolate in the article. The European definition of chocolate is dependent on cocoa content. Anything with a low cocoa content is called confectionery. I suspect that this study is about confectionery – not dark, cocoa rich chocolate, but the article does not try to define or clarify this. There is mention in the opening paragraph of the article that “chocolate is often consumed as a sweet” (is this alluding to confectionery?) Later on the article notes “chocolate products are often rich in sugar and fat”. Chocolate products?! Are we talking chocolate cake, chocolate ice cream and/or chocolate biscuits now as well as confectionery? Dark chocolate is not rich in sugar, so can we presume that we are not talking about high cocoa content chocolate?

The final paragraph details a study done on rats where they were fed “cocoa-derived epicatechin”. Cocoa Powder is highly nutritious – exceptionally rich in several minerals such as magnesium, phosphorus, potassium, manganese, zinc, copper and iron. As an example, 100g of cocoa powder delivers 80% of the Recommended Dietary/Daily Allowance of iron. It is disingenuous, however, to mention a study of a cocoa derivative when one is making headlines about ‘chocolate’ consumption and neglecting to differentiate between chocolate and chocolate products, let alone confectionery and high cocoa content chocolate.

4) A study finding needs to be plausible and associations claimed should be shown to have possible rationale. This study fails this test. Claiming an association between frequency of consumption, but not quantity makes no sense. The explanation offered is as follows and please note that this occurs in the rat study paragraph where we are still talking about cocoa-derived epicatechin and rodents:

“Cocoa-derived epicatechin, specifically, is reported to increase mitochondrial biogenesis and capillarity, muscle performance and lean muscle mass and to reduce weight…” What does this have to do with the frequency of consumption of chocolate products with no measure of cocoa content, let alone epicatechin, in humans?

5) The study could have asked what colour socks the person wore or what American football team they supported.  There may also have been a tiny relationship between how frequently people ate chocolate and the colour of the socks they wore or BMI and the football team supported – any observation between whatever frequency of consumption of whatever was presumed to be chocolate and BMI is equally daft.

Would the headlines then have been “Blue socks ‘may help keep people slim’”!?

The BBC were among the first to pick up the story and the story was featured extensively on BBC Breakfast TV and Radio 4 on Tuesday 13^th March. Interestingly, John Humphries asked the pertinent question of science reporter Tom Feilden “We’re all going to die – let’s accept that. So what does this lower risk mean?” Tom couldn’t answer the question. He replied “It’s very difficult to unpick these statistics – these numbers are used as bald headlines.” Quite so!

So let us try to unpick the data and see what this article is all about:

At the outset we must highlight the error that this, and every similar study, makes. All that a study like this can even hope to achieve is to suggest a relationship between two things. To then leap from an observed association to causation or risk is ignorant and erroneous. This article makes this mistake – as has every other study I have reviewed demonising red or processed meat over the past year such as this or this.

The studies used in this article

There have been two large studies in America where people have been asked to record dietary intake, smoking, activity, weight and many other factors over a long period of time. The data from these two studies has been analysed retrospectively to look for patterns. This was not a study designed to review meat consumption over a period of time – some data just happens to be available and it has been reviewed to make headlines about meat consumption.

The two studies are the Health Professionals Follow-up Study (1986-2008) (abbreviated to HPFS) involving 49,934 men and the Nurses’ Health Study (1980-2008) (abbreviated to NHS) involving 92,468 women. A number of participants from these two studies were excluded in this meat review. After excluding people with cardiovascular disease (CVD) or cancer at the start of the study and excluding people whose dietary responses were incomplete, this article proceeded to review data from 37,698 men in the HPFS and 83,644 women in the NHS. Diet was assessed by validated food frequency questionnaires and updated every 4 years.

The dietary questionnaire offered 9 possible responses for meat consumption, ranging from “never or less than once per month” to “6 or more times per day.”

Unprocessed red meat was assumed to be “beef, pork, or lamb as main dish” (pork was queried separately beginning in 1990), “hamburger,” and “beef, pork, or lamb as a sandwich or mixed dish.” The standard serving size was 85 g (3 oz) for unprocessed red meat. As this was an American study, the great American hamburger has been included in unprocessed meat – it is of course as processed as meat can be. Hamburgers account for approximately half of American ‘beef’ consumption[i] and should be categorised as processed meat. If someone has had a beef sandwich or a pork kebab or a lamb curry – this has also been deemed unprocessed meat. Hardly what Paleo types would call real meat!

Processed red meat included “bacon” (2 slices, 13g), “hot dogs” (one, 45g), and “sausage, salami, bologna, and other processed red meats” (1 piece, 28g).

The Data – Table 1

Table 1 (http://archinte.ama-assn.org/cgi/content/full/archinternmed.2011.2287) has the raw (baseline) data for the two studies separately categorised into quintiles for total red meat consumption (processed and unprocessed meat lumped together). The five quintiles take the lowest fifth consumption of red meat and then the next lowest and then the middle of the five groups then the second highest and then the highest. Table 1 is age standardised (to remove the impact of any age differentials between the different five groups of red & processed meat consumption) and it then lists other characteristics of the five groups.

Here is where the first problem emerges. As you can see for yourself in Table 1, Q1 is the lowest red & processed meat intake and Q5 is the highest. There are many other variables that correlate to the groups Q1 to Q5 – this is for the HPFS – the top part of Table 1:

- Physical activity, as measured by hours of metabolic equivalent tasks, falls from 27.5 in Q1 to 22.7 in Q2 to 20.2 in Q3 to 18.8 in Q4 to 17.2 in Q5. As red & processed meat consumption increases, so exercise falls. Could lack of exercise impact mortality?

- Body Mass Index – the average BMI for Q1 was 24.7; the average BMI for Q2 was 25.3; for Q3 it was 25.5; for Q4 it was 25.7 and for Q5 it was 26. As red & processed meat consumption increases, so does BMI. Could BMI impact mortality?

- Smoking – the percentage of people in Q1 who smoke was 5%; in Q2 it was 7.3%; in Q3 9.8%; in Q4 11.3% and 14.5% in Q5. As red & processed meat consumption increases, so does smoking – the top quintile virtually three times higher than the lowest. Could smoking impact mortality?

- Diabetes – the percentage of people in Q1 and Q2 with diabetes was 2%; in Q3 it was 2.2%; in Q4 2.4% and 3.5% in Q5. As red & processed meat consumption increases, so does diabetes. Could diabetes impact mortality?

- The interesting one was cholesterol. 14.8% of Q1 were recorded as having high cholesterol; 11.1% of Q2; 9.7% of Q3; 9% of Q4 and 7.9% of Q5. So, as red & processed meat consumption increases, cholesterol recorded as high fell. Could low cholesterol impact mortality? Given the protective nature of life vital cholesterol and the repair role that it plays in the body, it is highly likely that high cholesterol is protective against cancer and heart disease. Quite the opposite of what we have been led to believe in the interests of statin and plant-sterol-injected-low-fat spread profitability.

- Total calorie intake – the average daily calorie intake for Q1 was 1,659; the average daily calorie intake for Q2 was 1,752; for Q3 it was 1,886; for Q4 it was 2,091 and it was 2,396 for Q5. As red & processed meat consumption increases, so does calorie intake. Could calorie intake impact mortality?

- Alcohol intake – in Q1 an average 8.4 grams of alcohol were consumed daily; in Q2 this was 10.7; in Q3 it was 11.2; in Q4 it was 12.4 and 13.4 grams of alcohol were consumed daily in Q5. As red & processed meat consumption increases, so does alcohol intake. Could alcohol intake impact mortality?

The Nurses Health Study showed exactly the same correlations – the numbers were slightly different but the trends were the same. As red and processed meat consumption increased so exercise and high cholesterol fell; BMI, smoking, diabetes, calorie intake and alcohol intake all increased.

Table 2 looks at all mortality (I will stay at the all mortality level – the study does not stand up to scrutiny at this level so there is no point looking at cardiovascular (CVD) mortality vs. cancer mortality).

Table 2

Table 2 presents mortality data per quintile. The high level numbers are that:

- The HPFS covered 758,524 person years and there were 8,926 deaths in total: 2,716 attributed to CVD and 3,073 to cancer.

- The NHS covered 2,199,892 person years and there were 15,000 deaths in total: 3,194 attributed to CVD and 6,391 to cancer.

- The two studies combined, therefore, covered 2,958,416 person years and there were 23,926 deaths in total: 5,910 attributed to CVD and 9,464 to cancer.

The first point to make, therefore, is that the overall death rate was very small:

- In the HPFS, in 758,524 person years the overall death rate was 1.18% and the CVD death rate was 0.36% and the cancer death rate was 0.41%. Over a 22 year period, just over one in a hundred members of the study died.

- In the NHS, in 2,199,892 person years the overall death rate was 0.68% and the CVD death rate was 0.15% and the cancer death rate was 0.29%. Over a 28 year period, approximately one out of 150 members of the study died.

- In the two studies combined, in 2,958,416 person years the overall death rate was 0.81% and the CVD death rate was 0.2% and the cancer death rate was 0.32%. In the combined studies, fewer than one person in one hundred died in a 28 year period.

Table 2 is then supposed to have adjusted for all the other factors noted under the analysis of Table 1. The article says that the multivariate analysis adjusted for energy intake, age, BMI, race, smoking, alcohol intake and physical activity level. However, I don’t see how this can have been done – certainly not satisfactorily.

In Table 2 the raw data for deaths per person years for each quintile is presented. I have done a raw ratio (marked Z) on these numbers to show the following:

Health Professionals Follow up Study

Above, I have simply taken the raw number of deaths for each quintile over person years and then calculated this as a ratio. The Multivariate line is the one presented in Table 2 of the article. It is the alleged comparison between the five quintiles – using quintile 1 as the base of 1.00 and relating the other quintiles to this base number. This multivariate line is supposed to have adjusted for the fact that exercise and cholesterol went down and BMI, smoking, diabetes, calorie intake and alcohol intake all increased alongside red and processed meat consumption. It is supposed to have removed all those correlations to isolate meat consumption alone.

My death rate line (Z) should therefore have all the other variables included and the multivariate line should have excluded all the other variables. The multivariate line should therefore be substantially below my death rate line (Z) for every quintile and it isn’t. Indeed the raw data for deaths per person years shows that the death rate was lower in Q2 and Q3 than Q1 for total meat, unprocessed meat and processed meat. Look at unprocessed meat (not withstanding that this includes hamburgers and other junk that it shouldn’t) – the death rate in quintile 3 (Q3) is 0.99 vs 1.23 for Q1. As meat consumption increases from Q1 to Q2 and Q1 to Q3, so the death rate falls. Only in Q4 and Q5 does this reverse and it is in these quintiles that we saw the highest levels of BMI, smoking, low activity, high calorie intake, high alcohol intake and so on and these have clearly not been adequately allowed for.

The nurses study shows exactly the same pattern. The death rate falls in Q2 and Q3 vs. Q1 in all cases. In fact even Q4 is lower than Q1 in all meat groups. Only Q5 is higher than Q1 on my ratio of raw data and this is with none of the smoking, exercise, weight, diabetes, alcohol having been allowed for.

Nurses Health Study

The headline of the article

The key passage in the press release that attracted all the headlines was this:

“Unprocessed and processed red meat intakes were associated with an increased risk of total, CVD, and cancer mortality in men and women in the age-adjusted and fully adjusted models. When treating red meat intake as a continuous variable, the elevated risk of total mortality in the pooled analysis for a 1-serving-per-day increase was 12% for total red meat, 13% for unprocessed red meat, and 20% for processed red meat.”

This is what led to the big news story: “adding an extra portion of unprocessed red meat to someone’s daily diet would increase the risk of death by 13%. The figures for processed meat were higher, 20% for overall mortality…”

These numbers come from the bottom lines in Table 2 in the article. The bottom three lines in Table 2 come from the authors of the article combining all deaths in both studies from the multivariate model. They state that, using Q1 as the base line (1.0), the relative results for the other quintiles are as follows and they have added in a final column claimed to be the risk factor for increasing consumption of total, unprocessed or processed meat by one serving a day:

The 13% at the end of the unprocessed line is where the 13% headline comes from and the 20% at the end of the processed line is where the 20% comes from. I don’t know precisely how they have come up with these numbers. The corresponding consumption for each quintile was 0.25, 0.61, 0.95, 1.36 and 2.07 servings per day (for the HPFS). I suspect that their model allows them to look at the data for 1 serving vs 2 or half a serving vs one and a half and to compare ratios in this way.

None of this, however, reflects the facts from the raw data that Q2 and Q3 have lower death rates than Q1 in both studies and Q2, Q3 and Q4 are lower than Q1 in the Nurses study.

In summary

There are numerous key problems with this study – I’ll share seven:

1) This study can at best suggest an observed relationship, or association. To make allegations about causation and risk is ignorant and erroneous.

2) The numbers are very small. The overall risk of dying was not even one person in a hundred over a 28 year study. If the death rate is very small, a possible slightly higher death rate in certain circumstances is still very small. It does not warrant a scare-tactic, 13% greater risk of dying headline – this is ‘science’ at its worst.

3) Several other critical variables showed correlation with death rates – lack of activity, low cholesterol, BMI, smoking, diabetes, calorie intake and alcohol intake. These have not been excluded to isolate meat consumption alone. The raw data actually shows deaths rates falling with increased meat consumption up to the third or fourth quintile – and this is before all the other variables have been allowed for. This would suggest that meat consumption has a protective effect while weight, alcohol, calorie intake, lack of exercise and so on are all taking their toll.

4) Several other critical variables were not measured, which would logically correlate with certain meat consumption. Unprocessed meat inexplicably included sandwiches, curries, hamburgers (which come in buns) – has the correlation with bread, margarine, white rice, egg fried rice, poppadoms, burger buns, ketchup, relish or even fizzy drinks been correlated with the death rates? Indeed, Frank Hu, one of the authors of this meat study, is also quoted in today’s paper saying that one soft drink a day raises the risk of heart attacks.  It doesn’t of course – it is association at best, just as the meat article is – but one does wonder if that harmful soft drink was the one that just happened to be consumed with the hamburger or the bacon, lettuce and tomato sandwich ‘meal deal’?!

5) Hamburgers and pork sandwiches or lamb curries have been included as unprocessed meat. This is not a study of what real food devotees would consider unprocessed meat therefore. May I suggest that a study of consumers of grass fed ruminants would not deliver the desired headline? The lamb and beef grazing in the fields around me in Wales could not be further in health benefits from the hamburgers in buns and hot dogs in white rolls in fast food America.

6) We are all going to die. We have 100% risk of it in fact. We are not going to increase this risk by 13% or 20% if we have a hamburger and certainly not if we have a grass fed nutrient rich steak. This is headline grabbing egotistical academics doing their worst.

7) As I always consider conflict of interest, it would be remiss of me to end without noting that one of the authors (if not more) is known to be vegetarian and speaks at vegetarian conferences[ii] and the invited ‘peer’ review of the article has been done by none other than the man who claims the credit for having turned ex-President Clinton into a vegan – Dean Ornish.[iii]

All of this nonsense has given me an appetite, so I’m off to get my complete protein and essential fats plus the full range of B vitamins, ample fat soluble vitamins and lashings of iron, phosphorus, magnesium and zinc – also known as grass fed steak!

[i] http://www.meatami.com/ht/a/GetDocumentAction/i/48781

[ii] http://www.vegetariannutrition.org/speakers.html

[iii] http://archinte.ama-assn.org/cgi/content/full/archinternmed.2012.174

The five-a-day campaign is actually a different number-a-day campaign across more than 25 countries. The UK swears by five-a-day. The USA proposes nine-a-day: two and a half cups of vegetables and two cups of fruit every day. Australia suggests five portions of vegetables and two of fruit, where a portion of vegetables counts as 75 grams of cooked vegetables, one cup of salad vegetables, or one small potato and a portion of fruit would be one medium piece (150 grams), one cup of diced fruit pieces or canned fruit, or one cup fruit juice.

The European advice varies as follows: Denmark says eat six-a-day. The Irish have a food pyramid, not a plate (more American) and they go for four (plus)-a-day. The Swiss have five-a-day and tell citizens to go for a variety of colour in their choices. The Belgians and Austrians also favour five-a-day. Italy just says eat more fruit and vegetables – very libertarian. The Spanish have a pyramid with two rows to eat occasionally – the foods on these rows look like (red) meat, sausages, cakes and sweets – and then they have four rows to consume daily – in order of smallest to largest intake recommended – other meat/fish; dairy; fruit and vegetables and then grains. Hence, the Spanish have a free hand in choosing their number-a-day and they also have advice for moderate intakes of wine and beer along the side of their pyramid. The Greek food pyramid is simply called “The Mediterranean Diet” and they quantify three servings of fruit and six servings of vegetables a day. Latvia goes for percentages – 30% of daily intake should be in the form of fruit and vegetables. Germany (spot a centre of engineering expertise) has a three dimensional food pyramid indicating qualitative and quantitative nutritional information. They also have a staircase picture elsewhere on a public health website with fruit and vegetables on the bottom step (the largest group to be consumed); meat, fish and dairy on the next step; German sausages and whole grains on the next step and then other grains and finally junk on the final two steps.[i] This is getting closer to reasonable advice. I also heard anecdotally, from an attendee of the 2009 Amsterdam obesity conference, that the German delegates were recommending 500 grams of vegetables per day while fruit was not quantified. The Hungarians haven’t gone for a pyramid, or a plate – they have a house with no numbers apportioned. The French have five-a-day or fewer – interesting.[ii]

Where did five-a-day come from?

So where did the pick-a-number-a-day all start? It started as the “National five-a-day for better health” program in 1991 as a public-private partnership between the National Cancer Institute (NCI) and the Produce for Better Health Foundation. The programme started in California, the sunshine state, and has become the world’s largest public-private nutrition education initiative. All States in the USA have a five-a-day co-ordinator and, as we can see above, the programme has spread as far as Australia and Latvia. (Five-a-day has since been trademarked by the National Cancer Institute).

The National Cancer Institute was established in 1937 and is the USA government’s principal agency for cancer research and training. The Produce for Better Health Foundation can be found at the web site “fruitsandveggiesmorematters.org” and their purpose is to get us to eat more fruit and vegetables. In terms of conflicts of interest, we can’t move on without listing some of the sponsors of the Produce for Better Health Foundation:

-    Logistics firms: C.H. Robinson Worldwide, Inc.; Caito Foods, Inc.; Capital City Fruit; Coast Produce Company and J&J Distributing.

-    Specialist producers: Driscoll’s (berries); U.S. Highbush Blueberry Council (blueberries); Ocean Mist (artichokes and fresh vegetables); Giorgio (mushrooms); Columbine Vineyards (grapes); Nature sweet tomatoes; Potandon Produce (potatoes) and Paramount Farms (nuts and flavoured nut snacks).

-    General fresh produce firms: W. Newell & Companies; Eurofresh Farms; Giumarra Companies; General Mills (Green Giant brand); Sun-Maid raisins and dried fruit; Kagome juices and Duda Farm Fresh Foods.

-    Other: such as BASF (the world’s leading chemical company, and a provider of fungicides, insecticides and herbicides); Glad Products Company (containers, bags and ovenware); Nunhems USA (commercial vegetable seeds); The Kidney Cancer Association and McDonald’s.

With the exception of The Kidney Cancer Association and, ironically, McDonald’s, the above represents a list of organisations that stand to benefit if there were a dictat from government that citizens should strive to eat (at least) five portions of fruit and vegetables every single day. Although we may mind less about tomatoes and berries being sponsored, than sugar and white flour, this is still a conflict of interest.

Why five-a-day? Why not? It’s a memorable number. It would have seemed achievable and it was the number of digits on one hand and, I would suggest, no more scientific than this. It was never the outcome of evidence based, thoroughly researched, scientific investigation. It was a marketing campaign – and the most successful nutrition marketing campaign that the world has seen.

Having been launched with no evidence whatsoever, there have been numerous attempts since to post-rationalise and to justify this worldwide campaign. It must be noted at the outset that this was never intended to be an obesity campaign. The involvement of the National Cancer Institute suggests that it was intended to be a programme to help with cancer in some non-quantified way. If it were designed as a general healthy eating campaign – to what end? It is difficult to know what this programme was intended to be, other than an excellent commercial venture for all the companies involved at conception. With no evidence at the time (or since), of any benefit from eating a certain number of fruits and vegetables each day, it is incredible to realise how far this marketing programme has gone. Now, as with so many other elements of our diet advice, we reiterate the slogan daily with no idea from whence it came.

The Colorado Department of Public Health reviewed the campaign and reported that, from the introduction of the five-a-day Day for Better Health Program in 1991 to 1998, the percentage of Americans who ‘knew’ that they should eat at least five servings of fruits and vegetables each day increased from 8% to 39% and the average consumption of fruits and vegetables increased from 3.9 to 4.6 daily servings per American.[iii] Most conveniently, in terms of dates, there was an article in the Journal of the American Medical Association (JAMA) in 1999 called “The Spread of the Obesity Epidemic in the United States, 1991-1998”. This reported that, during this period (when fruit and vegetable intake increased by nearly 20%), obesity increased by 50%, from 12.0% in 1991 to 17.9% in 1998.[iv] I’m not saying that five-a-day caused this, but it certainly didn’t help.

Five-a-day and cancer

Let us turn to the evidence for the condition that five-a-day was intended to help – cancer. In April 2010 a study was published in the Journal of the National Cancer Institute written by Paolo Boffetta, as the lead of a large group of European researchers.[v] The study sought to quantify if cancer risk were inversely associated with intake of fruit and vegetables. The article analysed data from the EPIC (European Prospective Investigation into Cancer) study, involving 142,605 men and 335,873 women for the period 1992-2000. This review of almost half a million people found that eating five portions of fruit and vegetables a day had little effect on cancer risk and the very small difference observed could be explained by other factors. The study also grouped participants into five categories from the lowest intake of fruits and vegetables (0 to 226 grams a day) to the highest intake (more than 647 grams a day). Significantly, the cancer risk did not vary between the five groups. The overall conclusion of the study was that: “A very small inverse association between intake of total fruits and vegetables and cancer risk was observed in this study. Given the small magnitude of the observed associations, caution should be applied in their interpretation.”

In November 2010, the UK part of the EPIC study published their findings in the British Journal of Cancer[vi]. Professor Tim Key concluded that: “The possibility that fruit and vegetables may help to reduce the risk of cancer has been studied for over 30 years, but no protective effects have been firmly established.”

Five-a-day and nutrition

One of the key arguments presented as justification for the five-a-day campaign (upon which the UK Department of Health alone has spent £3.3 million over the past four years), is that fruit and vegetables are highly nutritious.[1] We must stop making general and unsubstantiated claims like this. A worldwide instruction to citizens of tens of countries, across three continents, should be based on clear empirical evidence (and that evidence should have been tested and verified before any public health advice was issued). Aside from the fact that there is no such evidence for the health benefit of eating a particular number of a random selection of fruit and vegetables on any medical condition, let us analyse this ‘nutritious’ claim theoretically – starting with vitamins first:

The fat soluble vitamins are A, D, E and K. The pure form of vitamin A (retinol), vitamin D3 and vitamin K2 are only found naturally in animal foods (meat, fish, eggs and dairy products) and we can proceed on the basis that vitamin D can only feasibly be consumed naturally in animal foods (unless one can consume 2.2 kilograms of sunshine grown mushrooms in a fat delivery mechanism daily). Seeds, nuts and their oils are the best source of vitamin E. Even where fat soluble vitamins are found in plant sources, as the name suggests, they need a ‘fat’ delivery mechanism. K1 is found in green leafy vegetables and avocado is also a good source. Because of the absence of a ‘fat delivery mechanism’, the K1 in, say, spinach has a bio availability (availability to the body) of 4%, which increases to 13% if it is cooked in butter.[vii]

Vegetables have negligible or zero fat content, so no natural fat delivery mechanism. Two fruits do have a fat content – avocados and olives. If we compare the best source for each of A, D, E and K from avocado or olives, we find that 100 grams of olives delivers the equivalent of 20 micrograms of retinol (assuming that the body is capable of converting carotenes to retinol). Lamb’s liver delivers 7,392 micrograms of retinol per 100 grams. That means we would need to eat three kilograms of olives (4,350 calories) or eight grams of lamb’s liver (11 calories) to meet the recommended dietary allowance of vitamin A. Assuming again that our carotene conversion is optimal, 70 grams of carrots could provide the retinol equivalent, but we would need to eat them with (ideally) butter for this to be absorbed. For vitamin D, avocado and olives score zero; 100 grams of herring provides 40.7 micrograms. Avocado beats olives for vitamin E content – with 100 grams providing a respectable 2.1 milligrams. Sunflower seeds, however, provide 36.3 milligrams per 100 grams and almonds 24.7 milligrams. Avocado contains 21 micrograms of vitamin K1 per 100 grams, which is valuable, but no fruit or vegetable can provide K2.

The water soluble vitamins include the eight B vitamins and vitamin C. The best sources of the B vitamins are meat (especially organ meat), fish, milk and eggs. Whole grains and dried yeast are also a good source of B vitamins, but fruits and vegetables do not appear on lists of top sources of B vitamins. B12, of course, is only found in animal products and therefore must be taken as a supplement by vegans (vegetarians can get B12 in milk and eggs).

So we are left with vitamin C and fruit and vegetables do win the top spots here. Guavas and peppers provide the highest single source of vitamin C from fruits and vegetables respectively – with 228 milligrams per 100 grams for guavas and 183 milligrams per 100 grams for raw yellow peppers. However, as noted earlier in this chapter, the USDA database records many animal and nut sources of vitamin C and in substantial quantities. The more commonly consumed fruits don’t compare quite so favourably with, say, the 43 milligrams of vitamin C per 100 grams of chestnuts: apples have 4.6 milligrams per 100 grams and bananas 8.7 milligrams per 100 grams. So, we don’t even need fruits and vegetables for vitamin C, although they can be good sources of this vitamin.

On to minerals – if we look at the minerals with which people are more likely familiar: the best sources of calcium are dairy products and tinned fish; egg yolks, beef, cheese and liver are the best source of chromium; iron is best provided by organ meats; iodine is found in abundance in fish and kelp (seaweed); magnesium and manganese are plentiful in nuts and whole grains; good sources of selenium are organ meats, fish and shellfish and zinc is found in oysters, liver, meat, cheese and fish generally. Potassium is the one mineral for which fruits and vegetables are the best sources. Potassium, however, can also be found in all of nature’s foods, so we don’t need fruits and vegetables to obtain this mineral. Dried fruits and dark green vegetables are good sources of iron, but the organ meats are much better sources.

In conclusion, the statement in the Dietary Guidelines for Americans: “fruits and vegetables are excellent sources of vitamins” is not evidence based. A more accurate statement would be “low/zero-fat fruits are a good source of vitamin C and not much else; fruits with a fat content (avocado and olives) are poorer on vitamin C and better on other vitamins, but still no where near ‘excellent’; vegetables are often a better source of vitamin C than fruit and can also provide some useful fat soluble vitamins when eaten with fat.” For a short and accurate statement, the guidelines should have said “animal products are unbeatable nutritionally”.

Is five-a-day still a good idea despite having no evidence base?

Even if eating a certain number of portions of fruit and vegetables a day does nothing beneficial for cancer and even if the vitamin and mineral analysis does not bode well for fruit and vegetables being a major benefit to health generally, does the five-a-day campaign still have merit? As I write about obesity, I will answer from that perspective. I can only conclude that five-a-day has not been a worthwhile campaign and I present the following arguments as to why it has in fact been deleterious:

-    There is an opportunity cost of having spent so much time and money embedding a message that has not helped obesity (to be fair it was never intended to) when the benefits of embedding an equally simple, but far more effective message, could have transformed the obesity epidemic. The single public health message, which could have made an immense difference, would have been “eat real food.”

-    If the message had been “swap five-a-day”, rather than “eat five-a-day”, this could have helped – provided that junk were swapped out and not meat, fish, eggs, dairy and nutritious foods. My personal experience, working exclusively in the field of obesity, is that people are trying to eat five-a-day in addition to everything else they are eating, not instead of. This can only worsen obesity and, of course, obesity has worsened dramatically since the launch of five-a-day.

-    As if it is not bad enough that people are trying to get their five-a-day on top of everything else, the means by which they are doing this is disastrous for obesity. People are adding more processed food into their diet trying to get their five-a-day. If you review internet advice sites for ‘how to get your five-a-day’, adding sweet corn to (white flour) pizza is one suggestion, eat tinned (syrupy) fruit is another, fruit juices and fructose rich drinks are frequently recommended. We are eating even more processed food trying to get our five-a-day, which is to our overall detriment.

-    Five-a-day is not helpful for the increasing number of people who are increasingly carbohydrate sensitive and for whom fruit and high-carbohydrate vegetables are best avoided.

-    Finally, for anyone who is overweight (that’s two thirds of the ‘developed’ world), unlimited (green) vegetables and salads should be encouraged, but fruit/fructose is best avoided.

The first lesson in nutrition sets out that the body needs macro nutrients (fat, protein and carbohydrate – the need for the latter is debatable) and micro nutrients (vitamins and minerals). The best providers of the essential macro nutrients are animal foods – meat, fish, eggs and dairy. The best providers of vitamins and minerals are animal foods again, with seeds and a few non animal foods (kelp and peppers) being useful. The most nutritious foods on the planet, therefore, are animal foods.

Where is the logic for our governments and dietitians telling us to replace the most nutritious foods on the planet with the one macro nutrient that we arguably don’t even need, and certainly don’t need in the quantities currently recommended? How can our dietitians be so enthusiastic about processed foods, so lacking in micro nutrients that they are invariably fortified? How did we get to the situation that low calorie is more important than high nutrition?

The attack on real food occurs at the highest level. Here is an extract from the Chief Medical Officer’s report for England 2009 (published April 2010): “Meat, butter, cream and cheese can play a part in a healthy balanced diet. In excess they can cause health problems. Their high level of saturated fat finds its way into our diet in biscuits, cakes and pastries, as well as in meat” (my emphasis). If any meat, butter, cream or cheese have ‘found their way’ into processed foods: a) this didn’t happen by magic – food manufacturers put them there; b) they will be the most nutritious ingredients in the end product; and c) this means that we need to avoid the processed foods themselves and not any real foods that may happen to be within them. This is rather like saying that grade A students are bad, because they might find their way into crime.

Is there a five-a-day that would be worthwhile?

After all this, is there a perfect five-a-day? I set about doing what should have been done before any of this started. I went back to the USDA nutrition database and tried to get the Recommended Dietary Allowances (RDAs) from just five foods. This can be achieved with 100 grams of liver, 200 grams of sardines, 200 grams of whole milk, 100 grams of sunflower seeds and 200 grams of broccoli (1,300 calories). There will be infinite combinations of real foods that can provide the RDAs, but I started from the ones known to be highly nutritious.

For interest, I repeated the experiment for a vegetarian diet and the biggest challenge became vitamin D. The RDAs could be met with five foods: 500 grams of whole milk, 450 grams of eggs (10 medium eggs), 300 grams of spinach, 250 grams of raw mushrooms grown in sunshine and 50 grams of sunflower seeds (1,360 calories). Dietary advisors applaud people for choosing a vegetarian diet, but then tell them to avoid eggs and to consume low-fat milk. It then becomes practically impossible for a vegetarian to meet even minimal nutritional requirements. I had returned to eating meat and fish before the research for this part of the book, but, this exercise gave me great concern about what lasting damage I may have done to my health during years of not eating meat and fish. Gwyneth Paltrow may also be re-evaluating her diet after sharing her medical experience on her health website (June 2010). Paltrow’s vitamin D levels were tested by doctors in New York, following a “pretty severe” bone fracture and they “turned out to be the lowest they had ever seen.”[viii]

Vegans can’t get B12 naturally and they would need to eat 2.25 kilograms of (raw sunshine grown) mushrooms in a fat delivery mechanism (e.g. vegetable oil) to get the ‘adequate intake’ for vitamin D and an unusual food like oriental dried radishes to get their calcium – and to repeat this daily. For completeness, the five vegan foods would be 2.25 kilograms of mushrooms, 175 grams of porridge oats, 25 grams of sunflower seeds, 100 grams of oriental dried radishes and 300 grams of spinach (in more vegetable oil) and a vitamin B12 supplement. Without the calories in the vegetable oil, the vegan basket adds up to 1,644 calories – the highest of all three sample ways of getting our nutritional requirement.

In my book The Obesity Epidemic: What caused it? How can we stop it? I show how the RDAs can be met with a basket of  nine-foods-a-day (liver, sardines, eggs, whole milk, sunflower seeds, oats, cocoa, spinach and broccoli). One of the problems of trying to pick just five foods is that we end up with many vitamins and minerals over, or under, represented in our diet. We should consume a wide variety of nature’s food. This nine-a-day would be ideal, but the list of foods is not catchy enough for a marketing campaign, which, after all, is what this was. This ‘perfect’ basket also wouldn’t lead to a large increase in fruit and vegetable consumption – which is what the 1991 meeting attendees were no doubt keen to achieve.

The biggest tragedy of five-a-day is that we missed the opportunity to deliver a message that could have made a difference to our health and weight. The drive to eat five fruits and vegetables a day would have been far better directed (and still could be) towards eating more of the most nutritious foods each day. Meat (ideally liver), fish (ideally oily), milk (whole), sunflower seeds and broccoli would be the optimal five-a-day. Mum and granny were right.

[1] Fruit is also widely promoted for its antioxidant properties: a) the antioxidant role in the body is best played by vitamin E and b) if we reduce our exposure to free radicals (processed food, pesticides, smoking, pollution etc), we need fewer antioxidants.

[i] http://www.fet-ev.eu/index.php?option=com_content&task=view&id=58&Itemid=116

[ii] The UK, USA and Australian references are in Chapter Eight. The other countries are detailed at the following site: http://www.eufic.org/article/en/page/RARCHIVE/expid/food-based-dietary-guidelines-in-europe/

[iii] http://www.cdphe.state.co.us/pp/copan/5-a-day/5ADAY.html

[iv] Ali H. Mokdad; Mary K. Serdula; William H. Dietz; Barbara A. Bowman; James S. Marks; Jeffrey P. Koplan, “The Spread of the Obesity Epidemic in the United States, 1991-1998”, Journal of the American Medical Association, (1999).

[v] Paolo Boffetta et al, “Fruit and vegetable intake and overall cancer risk in the European Prospective Investigation into Cancer and Nutrition (EPIC)”, Journal of the National Cancer Institute, (April 2010).

[vi] http://www.nature.com/bjc/journal/vaop/ncurrent/full/6606032a.html

[vii] www.nutritiondata.com

[viii] http://goop.com/newsletter/88/en/ – Gwyneth Paltrow’s personal web site.

It is, however, a great illustration of one of the many ways in which calorie counting makes us fat…

The snippet is called “Food Swaps” and recommends swapping a Pret-a-Manger Emmental cheese salad sandwich for half a crayfish & rocket sandwich (Pret have a ‘slim’ option for half a sandwich) PLUS a bag of popcorn PLUS a mango & lime dessert PLUS a bottle of carrot juice. What’s not to like getting all of that instead of one sandwich?

The problem is, as I have explained in presentations elsewhere (here and here as examples) that weight is not about calories – it’s about carbohydrates. Human fat tissue is something called triglyceride – a structure with three fats (fatty acids – whatever you want to call them) joined together on a ‘backbone’ of glycerol. Glucose provides glycerol and carbohydrates provide glucose. Hence, when we eat carbohydrates we are able to make human fat tissue – we are also able to store it because the same carbohydrates cause the release of insulin – the fat storage hormone. If we don’t eat carbohydrates, the body will break down the human fat structure to release the glycerol/glucose part for the brain and the fats will enter the blood stream to be used for energy.

In essence – only in the presence of carbohydrate can we store human fat tissue i.e. gain weight and only in the absence of carbohydrate can we break down human fat tissue i.e. lose weight.

So – the Pret-a-Manger web site very helpfully has all of these five products listed with full nutritional information. This confirms that, yes, the emmentaal sandwich has 494 calories and 9.2 grams of saturated fat, but it also has 19.8 grams of protein and 40 grams of carbohydrate. The four products combined have fewer calories and less fat (the latter is a disbenefit, not a benefit – as the UK is seriously deficient in fat soluble vitamins and therefore needs to consume more fat). However, the four products combined have 14 grams of protein and 62 grams of carbohydrate. The macro nutrients that will provide satiety and cell repair and all the functions that the body’s Basal Metabolic Rate needs are reduced (fat and protein) and the macro nutrient that will make us fat is increased (carbohydrate).

This is a classic example of the choices made by calorie counters. Because people trying to eat less than their body needs are constantly hungry and low in energy and nourishment and because they become obsessed with food, as a result of hunger and deprivation, they want to get ‘the biggest bang for the buck’. The most food for the fewest calories. This is exactly what this snippet is about – how can we get more food for fewer calories. As carbs approximate to four calories per gram and fat approximates to nine calories per gram (neither of these is accurate), calorie counters will also choose low fat options. As protein is normally fairly constant, lower fat means higher carb (in the above example, both fat and protein are reduced as carbohydrate increases).

Eating fewer calories and trying to get the most food for the limited calories that one has drives people down the route of eating more of the macro nutrient that makes them fat. Don’t follow this food swap advice – it will hurt your waistline – to say nothing of the impact on your purse of buying four Pret products as opposed to one!

Extract from The Obesity Epidemic

“There are lies, damn lies and statistics”, Mark Twain.

Have you ever wondered why you constantly hear “one in three people die from heart disease” and yet you don’t lose one third of your friends and family every year? The USA death rate from all causes for 2006 was 0.78%.[i] That means 777 people, per 100,000 residents of the population, died in 2006. Death certificates recorded 200 of these deaths as heart disease. So 0.2% of the USA population died from heart disease in 2006. If you have 500 friends, you are likely to lose one of them to heart disease during a year. If most of your friends are female, heart disease is so weighted towards males that you could have 620 female friends, or 405 male friends, with the same risk of losing one friend during a year. That’s still one lost friend too many, but there is also an age dimension to consider. You would need to know 166,667 children aged 5-14 to have a likelihood of one dying from heart disease (which would in turn most likely be a rare hereditary condition) and yet, if you know 100 people aged 85 and over, 22 of them are likely to have heart disease on their death certificate over the next year.

In 1950, staying with the same American data, the death rate from all causes was 1.45%. Hence, this has been virtually halved with advances in medical treatment. (I would argue that, had we maintained our natural eating heritage and advanced our treatment options in the way that we have, death rates could have been reduced further still). Of these 1,446 deaths per 100,000 people, 589 (41%) were recorded as heart disease. This is interesting per se as the World Health Organisation was only formed in 1948 and heart disease was a little recognised condition before then. By 1960, the death rate had fallen to 1.34% with 42% of those deaths recorded as heart related.

In 1970, the year that the Seven Countries Study was published, the overall death rate had fallen further to 1.22% and heart deaths had fallen to 40% of these. This could be interpreted as fewer than six people in 1,000 were dying from heart disease, or four in ten – depending on lies and statistics. The four in ten positioning provides the context for the impetus for change that preceded the 1977 Dietary Goals for the United States announced by Senator George S. McGovern, chair of the Senate Nutrition Committee.

“Heart deaths have halved”

I was reminded of these statistics with the headlines of 26 January 2012:

The Telegraph: Heart attack deaths halve in a decade.

Daily Mail: Heart attack deaths halve in eight years.

and The Heart.org: Heart attack deaths plummet in three EU nations

as just three examples.

The original article behind these headlines is here.

It’s a really excellent article – well written, well laid out, well explained, a great concept for a topic to research – far better than the sensationalist headlines that emanated from it. However, it did invite these headlines with the conclusion “From 2002 to 2010 in England, the age standardised total mortality rate fell by about half”.

This is where the extract from The Obesity Epidemic helps to show the two ways in which numbers can be presented. If we think (as many people currently do) that one in three people dies from  heart disease, these headlines will have us thinking only half a person in three or one in six will now be dying from heart disease. “I’ve got six friends, so only one will die, instead of two!”

It also reminded me of the section in Dr Malcolm Kendrick’s The Great Cholesterol Con where he showed how he can double our chances of winning the lottery – buy two tickets! We now have a one in seven million chance of winning whereas, with one ticket, we had a one in fourteen million chance. Most sensible people would realise that we still have naff all chance of winning the lottery, but our chances have doubled.

Looking at the section in the BMJ paper entitled “Trends in Mortality”, we can see that “From 2002 to 2010, the age standardised mortality rate from acute myocardial infarction per 100 000 population decreased in men from 78.7 to 39.2 and in women from 37.3 to 17.7.” That is, indeed, almost halved in men and slightly more than halved in women. However, look at those lottery numbers.

In 2002, not even 1 man in 1,000 died from acute myocardial infarction (a heart attack) and in 2010 not even 1 man in 2,000 died from acute myocardial infarction. Put another way, if you knew 1,271 men in 2002 you would likely know one who died of a heart attack. In 2010 you would need to know 2,551 men to have one likely die of a heart attack. These are still really low odds. Yes, they have halved (as they did in the USA between 1950 and 2006), but they are still really low odds. Thinking you need to know 2,551 men before one will die is rather different to thinking you will now lose one friend in six, rather than one friend in three.

Event rate and fatality rate

The death rate is a function of the event rate and the event fatality rate i.e. does a heart attack occur and is the heart attack fatal. The real contribution of the paper was the data analysis to see that the improvements in mortality rates were approximately split between these two factors. About half the reduction came from the event rate (fewer incidents) and the other half came from the fatality rate (those incidents that proved fatal). However, this was not the case across all age groups: “Changes in the event rate played a bigger part in middle aged people, whereas change in case fatality played a slightly bigger part in young and very old people. This can be explained by the fact that , while the average annual changes between 2002 and 2010 in case fatality rate did not differ substantially between age groups, the declines in event rate did.”

a) Improvements in the event rate were attributed to “During our study period, national survey data for England indicates that the prevalence of smoking, high blood pressure, and high cholesterol levels decreased, while the prevalence of obesity and diabetes increased.”

I would disagree with two out of three of these. Declines in smoking – and particularly the ban on smoking in public places from March 2006 (Scotland) to July 2007 (England) – should have had a difference in event rate. High blood pressure is a symptom, not a problem – the underlying problem needs to be explained and how this changed between 2002-2010 illustrated. I do not consider cholesterol to be a risk factor in heart disease – quite the opposite – it is one of the major repair tools at our body’s disposal. Hence there is insufficient explanation for change in event rate, unless smoking can explain the whole.

Also, the paper notes that “The annual declines in event rates were not statistically significant for men and women aged 30-54 and 85 and older, which raises the possibility that there was no real improvement in the rate of occurrence of acute myocardial infarction in these age groups over the past decade in England.”

b) Improvements in the fatality rate have long been attributed to faster response times for initial treatment and general improvements in treating people in those first critical few minutes when fatalities are most likely.

In conclusion

This is all about numbers – “Lies, damn lies and statistics”.

The headlines scream “Heart attack deaths halved” and indeed they have. But your chance of winning the lottery can still double if you buy two tickets and this doubling is pretty meaningless. A man’s chance of dying from a heart attack was 0.079% in 2002 – not even a tenth of one percent. In 2010 this chance was 0.039% – not even half of a tenth of one percent. For women the chances were 0.037% and 0.018% in 2002 and 2010 respectively.  Your personal chances of losing a friend from a heart attack were small and are now smaller. Your chance of winning the lottery is small and could be smaller. The headlines did not reflect this.

———————————————–

[i] Centres for Disease Control and Prevention, (Using age adjusted data), http://www.cdc.gov/nchs/hus.htm (data page), ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/Health_US/hus09tables/09contents_tables.pdf, (detailed list of data available).

The claim comes from a study “by the team behind Men’s Health magazine”. As you will be able to see from the link, the article lists 21 items and suggests that you swap one for the other. Examples include:

- Have crunchy nut cornflakes instead of Special K honey clusters to save 54 calories;

- Have half a Tesco simply peperoni pizza instead of half a Tesco cheese feast deep crust pizza to save 40 calories;

- Have a Flake instead of a Snickers to save 161 calories. You’ve got the idea.

The 21 items add up to a saving of 2,205 calories. The article then says that – if you save these each week you could lose two stone in a year!

Here’s the maths – 2,205 * 52 weeks = 114,660 calories. It is then wrongly assumed that one pound = 3,500 calories and so 114,660 is divided by 3,500 to assume that 32.76lbs would be lost in a year. The calorie theory (as this 3,500 assumption is known) is also supposed to be about fat lost alone. Hence, if you believe the theory, people should lose 32.76lbs in fat alone and more on top in lean tissue (sadly) and water – approximately 15% on top – so nearer 38lbs in total.

Here are a number of ways in which this is stupider than a very stupid thing!

1) One pound does not equal 3,500 calories. See here to save me duplicating the summary. Write to Men’s Health/The Daily Mail and demand evidence for this formula – can they succeed where seven UK public health and obesity organisations failed?

2) You will not lose 1lb for each deficit of 3,500 calories (and nor will you gain 1lb for each surplus of 3,500 calories). See here to save me duplicating the summary. The figure of an average of 11lb vs an expected 100+lbs has been confirmed in a few recent studies. This shows the sources of some of the 11lb examples. Hence you may lose a tenth of what you expect – in this case approximately 3-4lb – not 30-40lb!

3) Assuming that every deficit of calories is matched to the single calorie by the body giving up the equivalent in body fat is beyond absurd and yet it is assumed by this article and 99% of people working in the field of weight loss.

a) The body has to be in the biochemical state that it can break down body fat and this won’t happen if glucose is available in the bloodstream, or stored as glycogen, to use for fuel instead.

b) The body can and does adjust. If we put 100 fewer calories in to the body, it can adjust both our basal metabolic activity for the day and/or our energy used above the basal metabolic rate for that day. Put in 100 fewer calories and the body can just cross “keeping you warm” or “building bone density” off the’todo’ list for that day; the body can also make you tired and slow you down so that you use up 100 fewer calories being active. To assume that the body cannot and does not adjust at all – let alone by a single calorie, I’m sorry but there’s no other way to put this – is totally naive and stupid.

4) A calorie is not a calorie – as Jequier’s thermogenesis work showed (Eric Jequier, “Pathways to Obesity”, International Journal of Obesity, (2002).) Jequier found that the thermic effect of nutrients (thermogenesis) is approximately 6-8% for carbohydrate, 2-3% for fat and 25-30% for protein. Hence any 100 calories eaten is no longer 100 calories the minute it enters the body. Men’s Health would need to adjust for every macro nutrient for every food compared and even then points 1, 2, 3 and 5 here render the whole study nonsense.

5) Some calories have a job to do. Fat and protein calories to be precise. Let us say our average man needs 2,605 calories a day (as the government has decided), if he exercises 1-3 times a week, the Harris Benedict Equation tells us that approximately three quarters of these calories will be for basal metabolic needs (the BMR) and a quarter for energy/activity over and above this. The BMR needs fat and protein. Hence approximately 1,900 calories are needed for the BMR and approximately 700 on top of that for other activity for the day. This means that Mr Average needs to eat 1,900 calories in the form of (quality) fat and protein and 700 in the form of carbohydrate (or fat – fat can equally be used for energy – protein can too, but it’s less efficient).

So, back to Men’s Health, if our person eats 8.8 Snickers, at 296 calories each this will deliver the 2,605 daily calorie intake. If Mr Average eats 8.8 Flakes instead – they have ‘saved’ 1,416 calories and Men’s Health assumes that this will deliver a weight loss of 1lb for every time two and a half times that this 1,416 saving is made (3,500 calories). This is nonsense. Mr Average only needed 700 carb calories (he actually needed zero, as he could have fueled on fat, so I’m being generous). Empty junk confectionery calories can do nothing to build bone density, fight infection, repair cells (BMR) etc. Hence, eating Snickers, Mr Average consumed 1,900 effectively useless calories, which can only be stored as fat and thereby make him fat. With the Flakes, Mr Average still consumes more carbs than he needs and still gets fat. Mr Average also gets sick by the way -  with either option – Men’s HEALTH!

The final point to make is that virtually every food on this “Eat this, Not that” list is complete junk – the tuna in water is the only decent product out of 42 products. Tuna doesn’t come naturally in vegetable oil! Men who care about their health shouldn’t even get lamb from Tesco – they should get grass grazed quality lamb from their local butcher. Pizza, processed ham, oven chips, confectionery, Quavers, Discos, Mr Kipling rubbish, Magnums, Vienettas have no place whatsoever in a health diet – for men or women.

If you want to lose weight – eat real food and nothing but real food – meat, fish, eggs, veg, salad, dairy products should be the staples and then nuts, seeds and fruits in season in moderation. Grains – ‘whole’ or otherwise – are just glucose with a few or very few vitamins and minerals. Animal foods will always beat a starchy carb in any nutrition contest.

Here’s the maths!

One fairly small (5 inch diameter) Duchy Original Christmas pudding contains 2,839 calories (313 per 100g)

We live 27 miles from Bristol. This site tells me that a 110lb person would use up 1,482 calories in 9 hours walking 27 miles at 3 miles per hour. Hence I have to walk there and back to ‘use up’ over 2,800 calories.

However – and this is something I only realised writing this blog that all calories burned calculators include the Basal Metabolic Rate. Hence, I would need to allow for what I would have been doing had I not been walking to Bristol and deduct this – because, by walking, I have only burned additional calories. If I had been writing for 9 hours instead, I would have used 808 calories, so, walking to Bristol would use 2,000 calories.

Just as well that none of this calorie stuff amounts to very much. If you want to be fit – be active; if you want to be slim – don’t eat Christmas Pudding!