I have just finished reading The Pioppi Diet: A 21-Day Lifestyle Plan. It is co-written by cardiologist and omnipresent anti-sugar advocate, Aseem Malhotra, and documentary filmmaker and former international athlete, Donal O'Neill, and presents a low-carb, high-fat (LCHF) revision of the Mediterranean diet. The book is a follow-on from the documentary, The Big Fat Fix, during which Malhotra and O'Neill visited the Italian village of Pioppi (formerly home to Ancel Keys, whose research in the 1950's linked saturated fat and heart disease and whose work is habitually dismissed by LCHF advocates as corrupt junk science). The book tells us that the people of Pioppi (pop: 197) are unusually long-lived (although we never see evidence of this beyond examples of anecdotal encounters with sprightly elderly men) and that this is due to a diet low in refined carbohydrates and rich in saturated fats (and particularly olive oil), fruit, vegetables, nuts, fish and modest amounts of red meat and red wine. They also credit the health-promoting, stress free atmosphere of the village, the positive effects of of lifetime of physical labour and the restorative effects of a regular siesta for the longevity of its inhabitants. These diet and lifestyle characteristics are then strategically appropriated in the book to form the Pioppi Diet (which is given the oxymoronic subtitle: 'A'21 day lifestyle plan').
The early chapters of the book adopt the familiar 'myth-busting' posture of popular LCHF books, mobilising claims to a science uncorrupted by the influences of Big Food to debunk received wisdoms surrounding the role of sugar and saturated fat in health; exercise; cholesterol; insulin resistance; and energy balance. While there are clearly interesting debates to be had here about food and health, I'm with Ben Goldacre when he argues that "the most important take-home message with diet and health is that anyone who ever expresses anything with certainty is basically wrong, because the evidence for cause and effect in this area is almost always weak and circumstantial, and changing an individual person's diet may not even be where the action is" (2009: 129). Their cherry-picking of the science and the reliance on single nutrient accounts of complex health problems are trademarks of the genre, and readers should also question how turmeric and coconut oil - hardly Pioppi staples - end up taking such pride of place. I would also like to see the look on an Italian waiter's face if I ordered an espresso mixed with a teaspoon of coconut oil, a teaspoon of turmeric, a teaspoon of organic raw cacao powder and a teaspoon of ground cinnamon. They also maintain a contradictory position towards weight, claiming that there is no such thing as a 'healthy weight' but rather a 'healthy person' while wielding of obesity statistics in a horrified manner. But these are all topics for another day. Instead, I want to focus on the dislocation of the diet, in spite of the book's insistence to the contrary, from the everyday lived experiences of the people of Pioppi. And in particular, I want to focus on Pioppi's mysterious disappearing women (and their invisible labour).
The longevity of Pioppi's inhabitants is not evenly spread according to Malhotra and O'Neill, and we are told during an introduction to the village that "in this region, the men, who work for eight hours a day, every day, in the fields, their entire adult life, outlive the local women"; and "If the research aligning mobility with ten-year mortality rates (death from any cause) points to the importance of strength, balance and power as we age, the men of Pioppi need not worry" (pp. 12-13). No mention is made of why the men outlive the women, and no consideration is given to the ways in which women's lives might be facilitating male longevity. For example, we are offered a vision of an 8-hour day of male physical work embedded in a life of relaxed sociality, but it is unlikely that the women are fortunate enough to have only an 8 hour working day given that they are likely to be responsible for the domestic and reproductive labour of the household, continuing long after the men of the village have completed their labouring day. Malhotra and O'Neill also celebrate social interaction and community, highlighting how the elderly people could be seen walking and chatting in groups around the village, but they do not consider the unpaid labour performed primarily by women of caring for elderly relatives; and in celebrating what they imagine (but cannot demonstrate) to be the sound Pioppian sleep, they ignore the sleeplessness of those caring for young children, the elderly, the sick or people with disabilities. Indeed, in this idealised world, and in common with many lifestyle programmes that so thoroughly celebrate male physicality, there is no serious consideration of disability or chronic illness beyond the assumption of its preventability. As Malhotra notes, "given a choice, I'd rather drop dead healthy than live the last decade of my life with a disability I could have avoided" (p. 21). Revelling in the absence of "negative rumination" among those they met in Pioppi, the private realm to which women are so easily relegated remains hidden, and they certainly made no effort to seek it out in their visit to the village, focusing only on its public face - a face which, given that tourism is a key part of village life (it has UNESCO protection as the home of the Mediterranean diet), is likely to be a carefully curated one which fits the narrative of healthful longevity for which it has become famous. A further question along these lines arises in claims that both men and women would historically have experienced periods of food scarcity - a finding that they translate into a recommendation of intermittent fasting. We are offered the vision of men heading out to work in the fields without food, but it is also important to ask how available supplies were divided up within the household. For example, as in many other cases of scarce resources globally, male needs could have been prioritised to the detriment of women and children. I'm only speculating here, but without evidence, we cannot assume that men and women experienced this scarcity and fasting equally.
This inability to consider the everyday lives of women is evident in a discussion of stress and the long-term impacts of trauma. They cite a 2012 paper describing a study of women who were the long-term carers for chronically ill children. The women experiencing the highest levels of distress were identified as having the shortest telomere lengths, which is interpreted as equivalent to 10 years of ageing. But...never fear, because according to Malhotra and O'Neill, "just three months of stress-reduction interventions such as meditation, Pilates or yoga, combined with changing one's diet and doing the right type of regular activity can reduce telomere attrition and may even slow down the ageing process" (p. 79-80). Aside from the heavily qualified possibility of a positive outcome from all this stress-reduction activity, the prospect of advising a woman weighed down with onerous caring responsibilities for her sick child to do some Pilates and change her diet is crass and callous, rendering her distress her own problem to solve. One can imagine that well-funded social care and support might go a lot further in improving her health and quality of life. In a similar vein, we are told that Malhotra recommends walking to all his patients since it is "freely available, super-effective and open to all. No excuses" (p. 121). Except this too fails to take into account the woman who can't leave her sick child or elderly relative, whose neighbourhood isn't safe for a woman to walk alone, or whose disability means that walking isn't safely accessible.
The absence of women from the idealised and fanciful story of Pioppi is only one of its discrediting features, but for me, constitutes a fatal flaw.
Thursday, 29 March 2018
Saturday, 24 March 2018
The Blueberry Muffins Survey
Earlier this week, Action on Sugar and the Obesity Health Alliance reported the results of their "Blueberry Muffins Survey" - a survey of the sugar content of a range of blueberry muffins available at supermarkets and in other out of home (OOH) outlets such as coffee shops. Drawing on nutritional information provided by outlets, or in a handful of cases, analysing the muffins in a lab to determine sugar content, the report compared sugar content, concluding:
1. Blueberry muffins are not a healthy snack, with 17 / 28 samples exceeding the daily sugar allowance for a small child (6 teaspoons)
2. Muffins from OOH outlets were bigger and more sugary than those from supermarkets.
3. The sugar content of the muffins varies between outlets.
4. The variation in sugar content and portion size shows that there is plenty of room to adjust content and portion sizes to meet the Public Health England of a 20% sugar reduction by 2020.
5. 42% of products provided full nutrition info at the point of sale, with a further 29% displaying limited information.
The report concludes with the following recommendations:
1. Products should be reformulated to reduce sugar content and muffin size.
2. All manufacturers, retailers and OOH outlets should publish full nutrition information, including traffic light labelling, at point of sale.
I'm not sure that we needed either a survey or a big press fanfare to learn that cakes have sugar in them; that some cakes are bigger than others; and that bigger cakes have more sugar than smaller cakes. But the survey also raises some more serious questions for me about the way sugar is being reported and the assumptions upon which recommendations are being made.
First - the choice of the blueberry muffin. They claim they picked this particular item "due to their wide availability, indicating their popularity", but this must apply to many baked goods. The key findings, however, provide a further clue to the blueberry muffin choice, declaring that 'blueberry muffins are not a healthy snack" - an assertion that appears to counter a prior claim that they are. There is an unspoken assumption here that consumers are mistakenly motivated to buy the blueberry muffins (rather than, say, chocolate ones) because the presence of fruit codes them as a healthy option, although no evidence is provided to support this premise. Furthermore, no data is provided on who is purchasing and consuming the muffins, and how regularly. Following on from this, if we understand what constitutes a 'healthy' choice as contextual rather than absolute, then it's entirely possible that the selection of a blueberry muffin is an informed attempt to reduce dietary sugar. For example, the Costa blueberry muffin has 28.6g of sugar per muffin (approx 7 teaspoons)*, placing it 14/28 among the chain's cake offerings for sugar content. However, a health-conscious consumer might have switched from their regular carrot cake (56.9g of sugar) or the triple chocolate muffin (38.6 g of sugar) to the lower sugar blueberry option, achieving a sugar reduction that far exceeds the 20% PHE sugar reduction target.
Second - like all "hidden sugar shock" media stories, the report assumes, firstly, that reformulation is a benign process, and second, that it is a lack of information that leads people to foods identified as problematically high in sugar. In the case of reformulation, history has some warnings for us. Trans fats - now widely perceived as harmful to health - were introduced as part of efforts to reduce saturated fat in food, and the increased demand for low-fat foods led manufacturers to introduce higher levels of sugar to preserve texture and palatability. Calls for the reformulation of processed foods should always begin with questions about how those reformulations will be achieved and at what potential costs. And secondly, the belief in the power of information through labelling to change purchasing and consuming behaviour is not supported by the current evidence. A 2018 Cochrane review on nutritional labelling, looking across a range of laboratory and real-world contexts, concluded that while labelling may impact on purchasing and consumption, the evidence is of too low quality to reach confident conclusions. Problematically, the review also concludes that in "the absence of observed harms", labelling could be used as part of a wider set of anti-obesity measures, but as with reformulation, I would question the assumption here that even if not effective, a move towards visible labelling is at least benign. For example, if we take the demands from Change4Life to be "Sugar Smart", we can see a potentially stigmatising shift of responsibility for health through food onto individuals, whose 'bad' choices are patronisingly rendered failures to be 'smart'. Furthermore, the focus on labelling assumes that people select 'unhealthy' foods because they don't know any better, but that once they know, they will change their eating behaviours and tastes to more closely match those of those advocating dietary change. This assumption dislocates food from its social context in ways that have the potential to exacerbate rather than ameliorate social inequalities, and to strip food of its affective and cultural meanings. Consequently, when, as in this report, we are told that "we are all eating too much sugar", who is included in this 'we' requires careful consideration.
This may seem like a lot to make of a short report about something as banal as muffins, but it is precisely in these wide-eyed "hidden sugar shock" stories that we can see in action the reductive and dislocated understandings of health and food that govern mainstream anti-sugar discourse.
And if anybody is asking, mine's a (vegan) chocolate muffin, please.
*The OHA press release for the report includes a footnote from Costa Coffee which notes that that in the report, the Costa blueberry muffin is listed as containing 40.3g of sugar. This was the result of a mistake on the Costa nutrition information pages for January - March 2018 and has since been amended (to 28.6g per muffin).
1. Blueberry muffins are not a healthy snack, with 17 / 28 samples exceeding the daily sugar allowance for a small child (6 teaspoons)
2. Muffins from OOH outlets were bigger and more sugary than those from supermarkets.
3. The sugar content of the muffins varies between outlets.
4. The variation in sugar content and portion size shows that there is plenty of room to adjust content and portion sizes to meet the Public Health England of a 20% sugar reduction by 2020.
5. 42% of products provided full nutrition info at the point of sale, with a further 29% displaying limited information.
The report concludes with the following recommendations:
1. Products should be reformulated to reduce sugar content and muffin size.
2. All manufacturers, retailers and OOH outlets should publish full nutrition information, including traffic light labelling, at point of sale.
I'm not sure that we needed either a survey or a big press fanfare to learn that cakes have sugar in them; that some cakes are bigger than others; and that bigger cakes have more sugar than smaller cakes. But the survey also raises some more serious questions for me about the way sugar is being reported and the assumptions upon which recommendations are being made.
First - the choice of the blueberry muffin. They claim they picked this particular item "due to their wide availability, indicating their popularity", but this must apply to many baked goods. The key findings, however, provide a further clue to the blueberry muffin choice, declaring that 'blueberry muffins are not a healthy snack" - an assertion that appears to counter a prior claim that they are. There is an unspoken assumption here that consumers are mistakenly motivated to buy the blueberry muffins (rather than, say, chocolate ones) because the presence of fruit codes them as a healthy option, although no evidence is provided to support this premise. Furthermore, no data is provided on who is purchasing and consuming the muffins, and how regularly. Following on from this, if we understand what constitutes a 'healthy' choice as contextual rather than absolute, then it's entirely possible that the selection of a blueberry muffin is an informed attempt to reduce dietary sugar. For example, the Costa blueberry muffin has 28.6g of sugar per muffin (approx 7 teaspoons)*, placing it 14/28 among the chain's cake offerings for sugar content. However, a health-conscious consumer might have switched from their regular carrot cake (56.9g of sugar) or the triple chocolate muffin (38.6 g of sugar) to the lower sugar blueberry option, achieving a sugar reduction that far exceeds the 20% PHE sugar reduction target.
Second - like all "hidden sugar shock" media stories, the report assumes, firstly, that reformulation is a benign process, and second, that it is a lack of information that leads people to foods identified as problematically high in sugar. In the case of reformulation, history has some warnings for us. Trans fats - now widely perceived as harmful to health - were introduced as part of efforts to reduce saturated fat in food, and the increased demand for low-fat foods led manufacturers to introduce higher levels of sugar to preserve texture and palatability. Calls for the reformulation of processed foods should always begin with questions about how those reformulations will be achieved and at what potential costs. And secondly, the belief in the power of information through labelling to change purchasing and consuming behaviour is not supported by the current evidence. A 2018 Cochrane review on nutritional labelling, looking across a range of laboratory and real-world contexts, concluded that while labelling may impact on purchasing and consumption, the evidence is of too low quality to reach confident conclusions. Problematically, the review also concludes that in "the absence of observed harms", labelling could be used as part of a wider set of anti-obesity measures, but as with reformulation, I would question the assumption here that even if not effective, a move towards visible labelling is at least benign. For example, if we take the demands from Change4Life to be "Sugar Smart", we can see a potentially stigmatising shift of responsibility for health through food onto individuals, whose 'bad' choices are patronisingly rendered failures to be 'smart'. Furthermore, the focus on labelling assumes that people select 'unhealthy' foods because they don't know any better, but that once they know, they will change their eating behaviours and tastes to more closely match those of those advocating dietary change. This assumption dislocates food from its social context in ways that have the potential to exacerbate rather than ameliorate social inequalities, and to strip food of its affective and cultural meanings. Consequently, when, as in this report, we are told that "we are all eating too much sugar", who is included in this 'we' requires careful consideration.
This may seem like a lot to make of a short report about something as banal as muffins, but it is precisely in these wide-eyed "hidden sugar shock" stories that we can see in action the reductive and dislocated understandings of health and food that govern mainstream anti-sugar discourse.
And if anybody is asking, mine's a (vegan) chocolate muffin, please.
*The OHA press release for the report includes a footnote from Costa Coffee which notes that that in the report, the Costa blueberry muffin is listed as containing 40.3g of sugar. This was the result of a mistake on the Costa nutrition information pages for January - March 2018 and has since been amended (to 28.6g per muffin).
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