The Public Health Collaboration Annual Conference

I spent last weekend at the annual conference of the Public HealthCollaboration, a charity I’ve been a patron of along with my wife Jane for the last 3 years. The conference was at the Royal College of General Practitioners in Euston Square and was attended by over 300 doctors, scientists, health professionals, journalists and professors. There was even at least one IT consultant, and I have to say that he was feeling somewhat out of place on Saturday morning surrounded by such eminent and dedicated people.

There was a packed schedule of 8 talks on each of the 2 days with subjects ranging from the history of fueling for endurance sports to curing epilepsy with a LCHF diet. 

The whole weekend was televised and will be available shortly on the PHC website. I’d like to highlight a small sample of the content that had the most impact on me.

Tom Williams and Simon Tobin gave a great talk on parkrun. Tom is the COO of parkrun which now has weekly 5k runs in over 530 locations worldwide. We had dinner with Tom on Friday night and it turns out that he is a low-carb advocate as well as a passionate believer in sport for all; there are even parkruns in prisons now and Tom likes to ensure that the focus of each event is not on the first finishers (we don’t call them winners!) but on the slower runners; the ones for whom 5k is a huge achievement. One of the things that Tom is most proud of is that the average parkrun time is getting slower!

Tom is pictured on the right here with Dr Ian Lake, a type 1 diabetic and marathon runner enjoying a very tasty LCHF dinner at Caffe Caldesi . 

Simon Tobin is a doctor from Southport and a previous correspondent of mine on this blog; he and the other doctors in his practice have been offering the LCHF diet as an intervention for patients with type 2 diabetes for several years now; the results are amazing with most patients managing to reduce or remove their dependence on drugs for managing the disease.  Remember that the best that a patient can hope for on drugs is that their condition might not get worse.

Simon often prescribes parkrun to his patients as a lifestyle intervention! This makes a lot of sense when you consider that over half of the diseases we suffer from are the result of lifestyle choices. Drugs are not the only answer and in many cases they are clearly the wrong answer.

Over the last 6 years Aseem Malhotra has become the poster-boy of the UK Real Food movement. He is regularly seen on TV debating with the likes of Susan Jebb the UK Government's advisor on obesity who is part if the team that advice the government on advice for healthy eating, or Professor Roy Collins who advises the NHS that just about everyone should be taking statins, although his own research suggests quite the opposite to anyone who doesn’t have a vested interest in the sales of Statins!  

When I first met Aseem 5 years ago he offered to share this slide with me but I forgot to follow up on his promise. 

One of his first major causes was to try to stop the sale of unhealthy and sugary foods in hospitals. When he had a heart attack patient wake up after an operation to be fed a burger and chips in bed he knew that something had to be done. His local hospital has now become the first in Britain to ban the sale of junk foods on site.

Aseem has published a number of contentious papers in the British Medical Journal, and he has developed a particularly tough skin having made a number of high profile enemies along the way. He is highly critical of the role of the food and drugs industry in influencing research and advice on matters of health; and equally critical of the eminent scientists who profit from this support whilst ignoring the latest scientific data on issues such as what causes heart disease.  

The best example of this is how the NHS still tells us that saturated fat and it's co-conspirator cholesterol are bad for us and will increase our risk of CVD despite the overwhelming evidence that they will not. There is so much at stake here in terms of NHS money and people’s lives, but it appears that what matters most is the imminence and incomes of those learned men and women who, by working so closely with the food and drugs lords have found themselves in the position of advising Her Majesty’s Government on what is best for her subjects. 

The phrase “eminence trumps evidence” is true at the highest level but it is good to see that increasingly, doctors are refusing to allow transparency and objectivity to be trumped by eminence and vested interests. A survey in Pulse, a publication for GPs, in October revealed that two-thirds of GPs were rejecting the Nice advice to offer statins to those at low risk.

Aseem received a well-deserved standing ovation at the end of his presentation. Interestingly this was attacked on twitter as evidence of cultist behaviour in the PHC movement. Anyone who was there would assure you that it was nothing of the kind. Just a spontaneous outpouring of gratitude for someone who has given so much. Exactly the same could be said of the next speaker.

Aseem and Tim

Tim Noakes – was just marvelous. He gave a self-deprecating account of his career, explaining how as a result of his research into nutrition for endurance sports he became the first producer of energy gels and the author of the bible of distance running (Lore of Running). He then tore this illustrious career apart by describing the faults in his methods and how they had been avoiding the importance of fat all along “because we didn’t understand the pathways by which the body uses fat for energy”.  Years later after reading the work of others he was not too proud or eminent to admit that his interpretation of his clinical data was wrong.

His favorite anecdote seems to be the one where back in the 80's the great Zimbabwean triathlete Paula Newby-Fraser accidentally miss-heard his advice and adopted a low-carb rather than a low-fat diet.  She then proceeded to win more Ironman races than anyone else in the history of the sport.

Tim has been involved in a high-profile court case for the last few years in which the Health Professionals Council of South Africa (HFCSA) have clearly tried to ruin his career because they take his recent research and publications on LCHF as a direct attack on their profession. Four years ago Tim gave some generic advice to a woman asking a simple question on Twitter and they have accused him of bringing their profession into disrepute.

You can find out all the details online if you wish but suffice it to say that I have never heard a sadder tale of the lengths that an eminent group of learned people will go to in order to protect their power and influence; ignoring simple evidence and attacking a kind and caring man in such a profound and prolonged manner. They are a disgrace to their profession and prove John Cleese (and more recently Assem Malhotra) correct when they said that 

“One should never forget the first principle of the old KGB. Always accuse your enemy of exactly what you are doing.”

The abuse that Tim has received as been awful, but the support he has gained is incredible and the whole fiasco has brought so much attention to the diet that he now feels that perhaps the human cost was worth paying.

And in many ways this story reflects the problem that we at the PHC were all gathered to discuss; the way that government advice is dictated by a small group of eminent men and women who seem intent on protecting their own dated research and opinions and incapable of changing their minds in the face of new evidence.

Professor Tim Noakes amazed the scientific world by tearing up the chapter on nutrition in his famous book and declaring that he got it wrong. Perhaps it’s now time for UK government health advisors like Professor Rory Collins and Doctor Susan Jebb to do the same thing.

Tim also mentioned the work of Virta Health, an American company providing structured programs for dietary intervention for the treatment of type 2 diabetes. There were not many plugs to commercial enterprises during the conference but this one deserved it’s airtime.

There is not much data on the longer-term impact of the diet on important health markers such as blood pressure, cholesterol and blood sugar, and this is what allows many of the diet’s detractors to state that the diet may work well in the short term but they have concerns about its longer-term efficacy and adherence. Well the data from Virta and Southport  (see below) is filling that void with overwhelmingly good news. Virta already have a very large study group and the papers that they are producing make fantastic reading. All of the important health markers being measured on their patients continue to improve in the two years that the data has been collected for. Comparing this data to the alternative of a life on Metformin and the likelihood of a painful early death I know what I would recommend to my loved ones.

When you consider that the huge majority of health issues relate to lifestyle choices it is a wonder that so little NHS time and investment is put into dietary interventions like this.

Which brings us on neatly to my final hero of the PHC conference Dr David Unwin. Four years ago a GP friend send me a link to a report written by Dr David Unwin and his wife Dr Jen Unwin from the Norwood surgery in Southport. The report described the early results of a trial that they had been performing with their diabetic patient in which they provided dietary advice as an option to patients. Patients who opted into the trial were given regular advice and assistance with adopting the LCHF diet. The results were very impressive and I wrote about them in this blog post 

David's talk provided a fascinating insight into the subject of fatty-liver disease, a precursor to diabetes and something that is entirely influenced by lifestyle factors such as diet and exercise.

For me the best bit of the talk was the way he dealt a huge blow to the detractors of the LCHF diet. If you research “LCHF diet” you will find lots of influential dietitians and health advisors whose principle criticism reads like this:

“The diet may have positive benefits in the short term but we have concerns about its long term use”.

These concerns arises from the lack of long term studies of the diet. This is despite the fact that of all the studies comparing the health effects of low-fat verses low carb diets there is an overwhelming majority in favour of low-carb. 

Much like the work by Virta Health but clearly in the impartial, public NHS domain, the Northwood trial has now been running for several years and they have been meticulously collecting data from all of the participants; they have now published data that shows the following:

And that’s not all that was achieved in the Northwood group. The risk of heart disease has dropped significantly according to the JBS3 score used to judge this risk

And so now we have the data. Of course it is open to scrutiny but I for one will be passing these last to graphics to anyone who continues to suggest that they have concerns about the long term use of the diet.

There were lots of other great talks at the conference; Peter Brukner (the Doctor on the Australia Ashes winning team) provided a very humorous introduction and update on the latest worldwide news. Zoe Harcombe was on fire as usual, destroying the ridiculous notion that “calories in = calories out” with a perfect explanation of the laws of thermodynamics and how they do not apply to weight or food. 

Zoe Williams (of Trust Me I’m A Doctor fame) gave an interesting talk about the importance of physical activity; her rather famous co-presenter Micheal Mosely was in the audience. Jen Unwin and Charlotte Summers made us think hard about whether we are addicted to sugar. Trudy Deakin, David Cavan and Professor Ian Broom gave us loads of fascinating insights into the practicalities of reversing type 2 diabetes for large patient groups. And Dr Scott Murray gave a great talk on factors influencing heart disease.   There were more talks but I had to take a few walks to stretch my limbs and give my brain time to digest everything!

Lastly, thanks to Sam Feltham the Director of the PHC charity. 

Jane and I have known Sam for several years and he is a great leader and motivator. He has the greatest respect of the many partners, patrons and members of the organization and he did a brilliant job of organizing a fascinating weekend. Sam puts his heart and soul (and his career) into everything he does.  Commitment like this is contagious, and the impact of the PHC is growing as a direct result of his work. 

 Well done Sam!

 

Dietary Advice and the Big-Food Wolf

The Big-Food Wolf is lurking in the corridors of Westminster disguised as government advisors but paid by food and drug companies. The wolf owns the lobbyists, paid solely to prevent our government from passing laws or making recommendations that might lower the dividends for the shareholders of their companies but might actually make our nation more healthy. 

The World Wide Wolf is spending 500 times as much on marketing its products as the World Health Organisation has to spend on dietary advice. The wolf is all around us; sponsoring the England Football Team, sponsoring and controlling ‘Our’ Olympics and educating our children to associate rubbish food with sporting success. 

I'd like to put it to the current and shadow chancellors and health secretaries that if they are brave enough to stand up to the big-food wolf and listen to the truth about the effects of sugar and carbohydrates upon diabetes, obesity and metabolic syndrome, then they could save tens of billions from future NHS spending and spend it on creating more jobs and better schools instead.

There is growing evidence to suggest that this level of saving truly could be made.

Dr Aseem Malhorta who is on the board of the Action On Sugar Group certainly thinks so. He points out that "Added sugar has no nutritional value whatsoever and causes no feeling of satiety”. So we should all ask ourselves why it is there in such great quantities in our food when it has proven links with causing diabetes and other diseases (http://www.lowcarbdietnews.com/evaluate-lchf-treatment-diabetes/)

Action on Sugar aims to work with the food companies to lower sugar levels. They hope that a gradual lowering of the levels of added sugar would not actually be noticed by consumers and would cause a significant lowering of illness.

The typical response of the food companies is that obesity is not their fault as there are so many other factors involved. Coke is not the enemy if used as part of a “Healthy Balanced Diet”.  They also quote the nasty-ubiquitous line: ‘Anything is OK in moderation”. Would that also be true for cocaine I wonder?

The food companies also say that they are already helping to educate us about food choices. Perhaps someone should devise a test on the subject and see what percentage of the population passes it. 

At the same time, each food company thinks it’s alright to suggest that there is room on our ‘healthy’ plate for their unhealthy food. Just how big is that plate? His critics like to portray Dr Malhorta as a bit a “quack”, which is a shame as he brings evidence to the debate where the food industry just brings childish excuses.

Despite getting fatter and less healthy the British public doesn’t like being told what to eat, do we?

I for one have found that since I have been on a LCHF diet I no longer need much sugar at all to get a taste of sweetness in food should I want that. My favorite dish of Greek yogurt and full cream with crushed nuts and preserved ginger tastes sweet to me, and yet it only has about half a teaspoon of sugar in it. Compare that to the 7 teaspoons in a can of Coca-Cola or the 6 teaspoons in a serving of Jordan’s Granola (this is a normal 100g serving mind you, not the paltry 45g recommended on the box that is clearly not big enough for normal people). 

Sugar is addictive and like most drugs we can reduce our dependency on it if we try hard enough. So perhaps Action On Sugar are taking the most pragmatic approach possible.

A Calorie is NOT a Calorie

According to NHS Choices website (http://www.nhs.uk/Livewell/Goodfood/Pages/eatwell-plate.aspx) the key to a “healthy balanced diet” is

• ·       Eating the right amount of food for how active you are
• ·       Eating a range of foods – this is what balanced means

The first line of their advice contains a major assumption - "calories in = calories out".

The second line of advice is of no practical use at all. What range of foods? What balance?

After just a simple level of research into 'calories in=calories out'  you will learn that it is not how many calories you eat but WHAT YOU EAT that impacts on the body’s response to storing energy as fat. But still our conditioned response to fat people who say “I really do not eat that much” is to say we do not believe them.

The human body is a complicated machine, and our genetic make-up ensures that we all have many differences, and so the suggestion that if we all ate the same food and moved the same amount then we would all weigh the same is simplistic nonsense. But most of us, myself included I admit, have peddled that nonsense for years.

Tim Noakes (https://www.facebook.com/pages/Tim-Noakes/363196263770926 ) has suggested that we all have different levels of Carbohydrate Intolerance, and that our propensity to put on weight is related to our level of intolerance. Now this sounds simple enough to me, just in the same way that some of us are more or less tolerant of say wheat, lactose or alcohol.

So, repeat after me; “Not All Calories Are The Same!”

  

So what is a Healthy Balanced Diet? (or rather What Isn’t?)

Here is the NHS healthy eating plate:

As you can see there appears to be room on this plate (at the bottom) for a can of coke or a mars bar (albeit a rather small one).  The precence of this purple segment gives all sugary food manufacturers license to say that their product can be used as part of a “healthy balanced diet”. The flood gates are open!

Our school canteens (and the food outlets in our teaching hospitals!) are half-full of fizzy sugary drinks and fruit drinks. Look! It’s there at the bottom of the healthy eating plate, so surely this means that it is OK to have a sugary drink with every meal? Along with the fruit from the green segment of the place. And yet there as absolutely no need for it. There is more than enough energy being delivered by that huge yellow slice of carbohydrates. "But we're following the government guidelines", say the canteens.

While we are on that topic, there is nothing BUT energy being delivered by those carbohydrates, they have absolutely no nutritional value; that scares me and is the main reason I have chosen to try living on a LCHF diet. Why eat lots of something that does you no good?

So, sugary and fruity drinks are nutritionally redundant. Why not recommend drinking water instead? Why include these drinks on that plate at all? Unless perhaps the food industry lobbyists had some hand in designing the contents of the plate? This would not surprise me at all as most of the members of the government’s health advisory panels are either on the boards of or have received lots of funding from companies in the food and drugs industries. Many of them are professors, but can we rely on them to be impartial? Money talks. And it writes reports.

It took the moral colossus of our times Jeremy Paxman to get the chairman of Coca-Cola Europe to admit that perhaps the 44 teaspoons of sugar in a large sized Cinema cup of Coke might be too much. (See 2 mins 20 seconds into this https://www.youtube.com/watch?v=ugFock3p2xE).

Now lots of folks would argue that they never drink fizzy drinks anyway, so what’s the problem? We should all be allowed to make our own choices. Well, we are constantly being advised to eat foods that are low in fat, and you don’t have to look very hard to see that most low-fat foods have a tasty hidden ingredient to compensate for the loss of fat; sugar.

Look on the label of most processed foods and you will see one or more of the following in the list of ingredients.

So one way or another most of us end up consuming too much sugar.

In the WH Smiths in Edinburgh Airport half of the shop was dedicated to sweet snacks. The only item that I could find that did not have some sugar in it was water. Even the healthy-looking sandwiches had a teaspoon of sugar in them. Why?

Here is the specific NHS advice on sugary drinks: 

"Instead of sugary, fizzy drinks and juice drinks, go for water or unsweetened fruit juice (remember to dilute these for children, to further reduce the sugar)"

If we are not fond of water then we should be drinking fruit juice (fructose). At least they suggest watering it down, but does anyone ever do that?

So, we should drink fructose, should we?  If our livers have already had their fill of the carbs on that healthy plate and topped up our glycogen supplies then that fructose can do nothing but turn straight into fat and stay that way.  What is that fruity drink on our ‘healthy’ plate for exactly? Vitamin C perhaps? Nope; there is more than enough of it and all the other nutrients we need in the vegetables and meat that ought to be on that plate. There is simply no need for it to be there. Sorry, that’s not fair; it tastes nice. But so does Coca-Cola.

I think that this conflicts hugely with the picture that most of us have in our minds of a healthy meal, with a nice glass of orange juice to wash it down.

Regulation?
Another quote from my superstar of the month Aseem Malhotra comes from this fascinating article http://www.theguardian.com/commentisfree/2014/mar/16/big-food-in-denial-about-harm-of-sugar.  The compelling sentence in this article is this: “Regulation to protect consumers and children is clearly needed.”

The food industry say they would like to work with ministers and the NHS to provide even better education about food choices, and it seems clear that there is a general reaction against ‘The Nanny State’ telling us what to eat and what not to eat; but I suspect that this ‘education’ will not change a thing. For example, acording to the dietary advice on a tasty looking pot of breakfast yogurt in WH Smiths advertised with no added sugar, it has just 2 teaspoons of sugars (fruit based) in each portion. Read the smaller print and you see that the suggested potion size is riduculously small, just over one third of the pot. Clearly the pot is aimed at a single perrson (there is only one spoon); I could easily eat two of them. When we are making choices about take-away food we look at the item, not some portion of it. So we will be eating 6 teaspoons of sugar for breakfast, not 2. This is not education, it is obfuscation.

History tells us that legal intervention is the only way to get results.

In Helena, Montana a ban on smoking in public places was followed by a significant decrease in coronary heart disease. The ban was overturned after 6 months and the rates of CHD rose back to their previous levels. (http://www.bmj.com/content/328/7446/977)

Consider the recent change in the law on smoking. Up until a few years ago the tobacco industry dragged their heels to stop change. As recently as 1994 the CEOs of every major tobacco company in the USA testified to Congress under oath that they were convinced that smoking did not have an effect on heart disease. They lied in order to protect their shareholders. And so will the CEOs of Tate and Lyle and Kellogg’s if they have to.  

Since the ban on smoking in public was intruduced in the UK there has been a significant reduction in Asthma and premature births (http://www.bbc.co.uk/news/health-26770009).

The key here is that interventions can quickly show significant effects. I think that it is likely that only a change in the law on food labeling will have a significant effect on our health. Or preferrably a fundamental review of the advice being given to the British public about healthy eating.

So, who is afraid of the big-food wolf? Are the lambs in the fields of Westminster just waiting to be flattered, paid-off and slaughtered when the time comes?

Many people think that over the last 20 years politicians in this country have emulsified into a center-ground of quivering, fatty, homogeneous sludge. But what they do get excited about is our votes. If we demand a change in dietary advice, and they can see that their chances of re-election depend upon it then perhaps they will be prepared to stand up to the wolf in sweet clothing and demand a change. So we need to raise the profile of the issue; and that, in a small way, is what I have hoped to do today.

If you want to learn more about the bitter truth about sugar, then this is the best place to start. https://www.youtube.com/watch?v=dBnniua6-oM

Credits: Some of the information in this article was presented by Dr Asseem Malhotra in his lecture at the College of Medicine on May 1^st 2014.