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.