The Great Doughnut Debate

by Tracy Purbrick
Primary Care Dietitian

Is a doughnut intrinsically evil, or should we only ever judge it by the company it keeps? Or to put it another way, should foods be labelled good, bad or indifferent, as per the Multiple Traffic Light (MTL) system or blandly described with panels of percentages, as per the Guideline Daily Amounts (GDAs) approach?

The battle between GDA’s and the MTL system has been fought so vociferously that rather than educate the masses, the public has been left more bemused than enlightened. Incredibly, whilst the government was chief instigator of the MTL approach, it has displayed either monumental impotence or apathy in not standing by its own brainchild and making it law.

Whatever the MTL’s shortcomings (all eminently ‘tweakable’) it is quite scandalous that rogue elements of the food industry have been left blithely to do their own thing and thereby seriously undermine it. And whilst the two rivals are now being given some sort of showdown – with the promise to see which version the public prefers – exposure to GDAs is inevitably going to be greater.

After all, Tescos (the chief GDA rabble rouser) holds over 30 percent of the supermarket share, almost double its nearest rival. Whilst my fingers will be tightly crossed for a victory of common-sense and the emergence of a hybrid of colours and percentages, maybe this is also an opportunity to take the debate one stage back. What was the wisdom of the chosen nutrients selected in the first place: total fat, saturated fat, sugar and salt.

So to kick things off, why was total fat selected rather than energy? Scratch beneath the surface of most epidemiological studies and evidence relating disease to total fat intake is pretty flimsy. Just look to the Cretans, glugging back 40 percent of their calories as fat, yet keeling over with even fewer coronaries than the infamously more austere Japanese. On the other hand, evidence relating an increasing number of diseases to obesity is overwhelming, and obesity in turn hinges upon calories – regardless of which macronutrient they’ve come from, which is why people have been able to achieve weight loss on diets as diverse as the Atkins and Pritikins.

Next, whilst labelling saturated fat – a fat consistently linked with heart disease – is laudable, why is there no red light reserved for trans fats: saturated fat’s bigger, badder brother? Of course, there shouldn’t actually be any significant level of unnatural trans fats in the UK diet, since no level of intake from industrial partial hydrogenation is deemed safe.

Denmark has led the world in tackling trans fats, introducing such strict regulations that even if a Dane were to live off ready meals (something us Brits sadly excel in) they’d struggle to eat even 1g of the stuff per day. If the UK government hasn’t got the gumption to do the same, it should at least name and shame via food labelling those food products in which they lurk. At present, trans fats have no special billing of their own, making their appearance by stealth amongst the considerably larger total fat.

The other questionable nutrient is sugar (do I hear grumbles of dissent?). In the era of the glycaemic index and more importantly glycaemic load, sugar becomes little more than a red herring. We must surely ask ourselves why people want to know how much sugar a product contains and then question whether sugar labelling actually achieves that end.

If it is to enable better blood sugar control, then highlighting dietary sugar could actually be woefully misleading. How many patients with diabetes do we already see who’ve ditched the All Bran (17 percent sugar but low GI) in favour of Weetabix (only 4.4 percent sugar, but high GI)?

Science has long moved beyond the complex and simple carbohydrate paradigm, but Jo public still hasn’t and never will if we perpetuate this myth via labelling. If denouncing sugar is for our dental welfare, then again, sugar is only one part of the story. Other factors, such as stickiness of a food, acidity and frequency of consumption are also important. Yes – raisins are far healthier than sweets, but frequently chewed, they could both leave you edentulous.

And whilst switching from standard Pepsi to diet cola will certainly spare some caries and calories (the latter easily flagged up by my aforementioned calorie traffic light), the acid bath could still erode the smile off your face. The main problem with sugar is that it is frequently, but by no means always, a marker for nutrient poor food, AKA junk. So why don’t we aim our labelling at identifying just that, by not just flagging up foods with health claims, but those with health shames too.

The food industry has had things all their own way for far too long. They’ll happily brag that something’s good for your heart and print little heart icons to hammer the message home, but there’s a strange absence of warnings on foods that might actually be detrimental to health. I’ve yet to see an icon of a fat belly or someone clutching their heart having a coronary on a packet of crisps.

But that brings us back to the good food/bad food debate. The food industry’s position on this is clear: ‘there is no such thing as a bad food, only bad diets’, which underpins their main argument against the MTL system. But if there is no such thing as bad foods then how can there be any such thing as good foods.

The truth, as they well know, is that the ‘no bad food’ mantra has served our appetites for junk food and their pockets well. Perhaps it is time to admit that a doughnut actually isn’t very healthy and deserves all of the red lights it gets. And of course we’ll all continue to eat them, but as a treat on top of our otherwise healthy diet, rather than pretending it’s an integral part of it.

So without further ado, my proposed list for the eventual labelling victor: calories, saturated fat, trans fat (hopefully a category requiring a brief existence) glycaemic load and salt. Then, in tandem with nutritional claims, let’s make manufacturers own up to the nutritional underperformers too.

Maybe the image of a dustbin on any nutrient poor junk and sensible warnings on all cariogenic drinks of the particular dangers of frequent swilling. But whatever the eventual food labelling outcome, we should never lie in order to simplify.

Fatso and the gene genie

By Tracy Purbrick
Primary Care Dietitian

I should be fat! Descended, as I am, from somewhat corpulent stock and having spent my most genetically malleable months attached, not to a breast, but a bottle. Sure I’ve resisted my biologically bequeathed destiny for nigh on 39 years, but if the papers are right, I’ll be upsizing sometime soon.

The reason I am doomed is the discovery of yet another fat gene and thus yet another reason to surrender to my fat fate. Actually, whilst this gene, the fatso (FTSO) gene, has been heralded by many as an obesity gene first, even the briefest of Googles trawls up a myriad more. There’s the PPARgamma2protein, MC4-R, Sarb1b and so the alphanumerical list rambles on. But whilst you might quibble over its primacy in the fat gene race, with a name like fatso it’s certainly the most media savvy.

So just how certain is this latest gene at portending whom will be portly? Apparently possessing one of the fatso genes increases the risk of obesity by 30 percent, whilst inheriting two increases it by nearly 70 percent; still not a fat guarantee. Strangely, whilst half the population has one such mutant copy, the remainder of the population is skewed heavily towards having none. And even for the least fortunate 16 percent who do face the double whammy, the actual average weight burden incurred, is a rather unspectacular three kilograms. Even the study’s author concedes that worldwide waist inflation is due to diet, not genes. But, the fact that the gene pool hasn’t changed in the past 20-30 years and neither presumably has that of our increasingly hefty pets, is a minor botheration in the way of a good story.

So why do we need to cling to a gremlin in our internal workings to explain away our weight, when the first law of thermodynamics already does such a sterling job? Well, it’s because we all know someone who eats twice as much as us, with half of the wobble to show for it. Or so we like to believe. Yet the notion of the ‘thrifty gene’ has of late been somewhat debunked. If people who are obese do have a genetic nudge that way, it’s not via any pathetically sluggish metabolism. When notoriously podge prone nations are studied, they have been found to tell as many porkies about their diets as the rest of us. What transpires is not so much a thrifty gene, but if anything, (as posited by Andrew Prentice, a perennial pursuer of obesity truth), a greedy one!

That is, they eat more in response to environmental cues. This possibility has been further investigated in a recent study with kids. Faced with a barrage of TV junk food ads, virtually all of the little blighters doubled their usual snacking. But those kids whose bones were already ‘well padded’, scoffed most rapturously of them all. However, that doesn’t prove genetically induced gluttony, any more than it absolves them of a weaker will. What it does suggest though is that rather than fiddling around in the human genome, a little tweaking of the environment could work wonders faster.

Let’s face it, any obesity gene of significant prevalence is likely to be recessive, polygenic and of low penetrance, thus not particularly influential, difficult to pin down and easily overpowered by will power. Even assuming genes could explain away a penchant for KFC or a phobia for physical exertion, where would any genetic discovery take the majority of us, beyond motivational collapse? If we could summon up an obesity ‘gene genie’ by rubbing some kitchen crockery, how would we wish to tweak our genetics and what would be the wisdom of it?

The number one foodie’s fantasy has to be a turbo charged metabolism, enabling them to eat more (preferably of the chocolate, chips and cakes variety), whilst staying slim. However, by revving up the metabolism, you also rev up free radical production. Indeed the only diet so far proven to promote longevity is a hypo-caloric - but nutritionally dense one. And, of course, turning up the calorie burners, in the long run, probably wouldn’t even result in staying slim. Inevitably, people would just up the ante on what they ate, staying plump, whilst indulging ever more. So whilst their own plodding footprint might look the same, their carbon one would inevitably expand, in line with their shopping baskets and till receipts.

So how about tinkering with the works, so that people simply couldn’t lay down any fat? Well, that genetic glitch already exists in the form of Berardinelli-Seip Syndrome. The victims of this condition possess virtually no body fat. Sound enticing? Well, with no where to store fat on their bodies, it just swills around their milky bloodstream, giving them high triglycerides, insulin resistance and a 100 fold increase in cardiovascular disease. Oh, and they also have to inject themselves daily with leptin, one of the satiety hormones normally made in the fat cells, to stave off the constant gnawing hunger.

But, of course! Leptin, the anti-hunger hormone… that has to be the answer! Indeed, after the millions of pharmaceutical industry dollars already invested, there’s a financial imperative to make darned sure it is. But after the initial excitement over leptin discovery, it has stunningly failed to live up to its promise. Leptin deficiency is, disappointingly, exceedingly rare. So in a bid to get a return on their cash, researchers instead turned to a possible leptin receptor deficiency. Yet again, though, this affliction is hardly rife, affecting only eight people out of 300 in a group already pre-selected for severe early onset obesity. And out of those afflicted few, six were from consanguineous families. Cue the next possible use; slipping it into baby milk on the rationale that breast milk contains leptin, but bottle milk doesn’t and bottle-fed babies are more likely to become obese. Well, that ‘bottle to blob’ link has also been recently scuppered. More worryingly though, a link between leptin and obesity related cancer is suspected, with leptin found to trigger colon cancer growth.

All this study into subduing hunger ignores one inconvenient truth. Very few people actually overeat to the state of obesity because of hunger. How many patients do we see, who, like the unfortunates with Prader Willi, would be prepared to shovel down frozen chips or rummage around in the garbage for soggy leftovers?

If you’re waiting for a gene genie to save you from the urge to splurge, you’ll have to wait more than one thousand and one nights. So, if you excuse me, I’d better lace up my trainers. I’ve got a big fat legacy to run away from.

Dietitians or Eco-worriers?

by Tracy Purbrick
Primary Care Dietitian

Never before has the very business of existence been so complicated. T’was a time when the prime considerations for purchasing food were cost, taste and for the more discerning customer, nutrition.

Nowadays the consumer (a term in itself wrought with guilt) is expected to ensure that they also buy food that is fair-trade, organic and green. The result is shopping aisle angst, or paralysis by analysis, as the ethically conscious wrestle with these impossibly conflicting demands. It now would appear that dietitians are being asked whether we too should join in the fray and incorporate environmental issues into our practice (Dietetics Today, July 2007).

Well, for those working on national agendas, the answer may well be yes, but with caveats (more on that later). But for the majority of us who work close up and personal with the disease stricken individual, the answer simply has to be no. To do so would in itself be unethical and quite frankly many of us haven’t got a clue what we’re talking about, including me.

To illustrate both points, we need to look no further than the hot topic of global warming. It firstly has to be acknowledged that this issue is by no means cut and dried. In fact, there are numerous eminent dissenters to the current climate change dogma; though like David Bellamy they remain in exile from ‘decent’ society. But even if we are avid believers in man’s (and not Mother Nature’s) hand in climate change, do we as dietitians have any more knowledge on reducing greenhouse gases than the next person?

As a profession we have experienced the horrors of watching certain media ‘nutritionists’ spout their own half baked notions on diet. We may even have dealt with the resultant faddy food fallout in clinics. For us to take on environmental issues, of which we know nothing more about than what we’ve read in the tabloids, is just as dangerous.

As acknowledged in ‘Dietetics Today', if we wade in and simplistically discourage food miles, we could actually churn out more green house gases. Ironic as it seems, due to the difference in farming methods from those practiced abroad, more locally purchased produce may be more carbon expensive. But even when local producers do manage to spare the odd emission, is that a worthy price for denying a living to families in the developing world?

Many farmers in Africa have actually converted from crops their locals would buy, in order to export to the fickle West. If shoppers now diverted their pennies elsewhere these third world farmers will be financially devastated. Even the neat notion that reducing packaging is always for the good, could be leading us up a less than green garden path. We forget that packaging used to portion up a product, can equal less food waste (as well as less food consumption) and reduce the carbon costs involved in storage. Uneducated, knee-jerk reactions, get warm, ‘glowy’, self satisfied feelings…. not results.

As for the ethics of spinning environmental concerns into consultations, this is fraught with conflicts of interest. Do I advise my patient to drink cola instead of a smoothies, or crisps instead of blueberries because they might possess smaller carbon footprints? Do I tell the fitness fanatic to slow down and chill out, as all that hyperventilation is further fuelling the miasma?

And do I convert all of my patients to vegans, to spare the world of flatulent dairy cattle and carbon intensive meat production, even at the risk of turning some of my patients into osteoporotic, apathetic anaemics*. And what of my Asian or African patients? Do I steer them away from okra and aubergines to broccoli and carrots instead? Or do I leave them alone and create a two tier system, whereby you can only eat such ‘exotica’ if it is part of your culinary heritage?

Assuming we could weigh up all of these issues and fathom how to save our patients whilst simultaneously saving the planet, I’d like to know how we’ll find the time. You cannot administer watered down, compromised dietary advice, without giving explanations and rationale. That’s one discussion the hard pressed NHS dietitian certainly doesn’t have time for.

At the end of the day, patients come to the dietitian to talk about what ails them, not the planet. I don’t want to be in a crisis over whether to advise someone to lose weight for the sake of their health, or to cling on to the blubber to save on their central heating! We can’t jump on a bandwagon, no matter how strongly we personally may feel on the topic or how trendy it is. We are qualified to do our job and we would risk undermining the patients trust in us.

While it may have been stated that dietetics doesn’t exist in a vacuum, if you are going to tell your patients the simple, honest to goodness truth about food, that is the way you need to operate. In reality, when a dietitian advises 5 a day, they don’t say; choose blueberries rather than blackberries; that nitty-gritty should be left to the individual’s choice and conscience.

And back to the role of dietitians in lobbying and that unfinished business of a caveat. Yes, by all means dietitians can do their part. But wouldn’t their skills be better used in upholding the nutritional end of any debate, to ensure that environmental concerns are balanced with health? Whilst many of us may prefer the pitter-patter of tinier carbon feet, our first allegiance should always be to their owner’s constitution. Otherwise, surely we are in the wrong profession.

* Let’s face it, whilst a vegan diet can be healthy, it requires a darned sight more effort to achieve, than most people are willing to invest.

Let them eat cake

by Tracy Purbrick
Primary Care Dietitian

It’s that age old dining dilemma. You’ve remained teetotal and skipped dessert, whilst everyone else has continued to plough on from pudding to port. Do you magnanimously agree to just split the bill and cough up for the unwanted additional expense?

Or do you risk the communal disdain by whipping out your calculator and only paying your dues? A fine conundrum indeed. But what if we were to magnify the pounds at stake by a dozen or so decimal places? With a budget of over £90 billion, issues of obvious inequity become all the more galling. And that folks, sums up the current (dys)functioning of the NHS; a service touted as free for all, but of course, actually paid for out of all of our taxes. How much harder it then becomes to dig that little further into our pockets to cover for those who expect everyone else to pay for the consequences of their excesses. So obesity, with all its rampantly increasing healthcare demands, is the metaphorical dinner companion, who at shared expense chooses king prawns and caviar, whilst everyone else scrimps by on scampi and chips.

Incredibly though, the obese en masse appear to be outraged at the notion that their burgeoning demands on healthcare should be rationed. Indignant, as though this was some part of a petty moral crusade against fat people; not what it clearly is - an inescapable consequence of finite resources.

Now I actually have some sympathy for smokers. It might be much more politically correct to deny them medical care yet, in fairness, they actually give quite generously to the kitty. In fact, if obese people also paid proportionately more, no one would begrudge them as many new knees or heart bypasses as a surgeon could suture.

But whilst they continue to dip their chubby little hands ever deeper into our share of the national coffers, of course those who get up to exercise at dawn or display a modicum of dietary restraint are going to feel resentful. Clearly then, in the name of all that’s fair, a way of drawing a few more pennies out of the sloth rather than the svelte is called for.

Now before I hear that old refrain, that taxing fat people is taxing the poor…….it isn’t! Rich people nowadays, are pretty much just as fat. Besides, rather than just upping the taxes, it could just be a redistribution by charging more for those things generally correlated with getting fat and discounting those associated with being slim. Fast food and computer games could be amongst those things in the former camp, whilst fruit, vegetables, and gym memberships could sit in the latter. How’s that for positive social engineering? A little tinkering, no net increases in taxes, and they might even lose some weight into the bargain.

Indeed, the ideal is obviously that we all shed any excess poundage, thus not only improving costs, but also our own physical and mental wellbeing. The recent government strategy, ‘Healthy Weight, Healthy Lives’, has some useful ideas for achieving this. However, it is mainly geared towards kids, who are largely victims of their adult ‘carers’. In terms of the grownups, it’s pretty much limited to making the built environment less obesogenic, chucking in a few health screens and improving nutritional information.

Whilst for some, improving cycle lanes and nutrition labelling may push their energy balance back into meltdown mode, all too many obese people already know that a pork pie isn’t lean cuisine. Unfortunately, they just don’t care! Or rather, they might like to be slimmer, but not as much as they’d like another slice of cake, thank you very much.

The Government’s answer to this recalcitrant clan is somewhat ambiguous. In one breath, they are underlining the importance of individual responsibility, but in the next they are suggesting stooping to bribery aka, ‘payments, vouchers and other rewards’. Throwing more of our good money after bad. Apart from the ludicrous logistical impossibilities of such a scheme, there surely comes a point when the proverbial towel should be thrown in. You can lead a horse to water and all that.

As dietitians most of us have seen hundreds, if not thousands of overweight patients over the years. For every handful of patients who take our advice on board and genuinely make changes to their lives, there is always at least one, who utterly refuses to countenance any form of change. These are the ones with chips on their shoulders as well as in their cavernous mouths. The ones who feel deeply entitled to eat whatever they want and still be slim. That they are visibly otherwise, is merely an affront of Mother Nature. These are the people who lap up stories on fat viruses and fat genes, but resolutely, never a word of advice.

So on this point, I believe the Government needs to get it’s thinking straight. At some point, individual responsibility does indeed have to kick in. Once you’ve redesigned the built environment, taken to task the enabling food and drink industry and offered any advice and emotional support needed. If someone still wants to self destruct via their oral orifice, nothing anyone can do and no amount of money is going to stop them. And for these time wasters, who rob the more deserving of dietetic and other healthcare time I say ‘so long’ as they are being taxed on it, let them eat cake!

‘Get Real Productions’ brings you….The Emperors New Clothes, 2008 style

by Tracy Purbrick

Primary Care Dietitian

Cast:

The Emperor: Chloe Marshall, Size 16, vital statistics 39, 32, 41, Miss England contestant

The cheering crowd: the duped British public

The Little Boy: Monica Grenfell, nutritionist, previous Miss England Judge and author of plain-spoken article in The Daily Mail*

Welcome to this modern day adaptation of Hans Christian Anderson’s morality tale. For the edification of those who were denied this childhood allegory, T’is a tale of delusion and the power of normative social influence. A king is conned by crooked tailors who tell him his (non-existent) brand new suit is made of such fine cloth, that it’s invisible to anyone who’s stupid. Thus, not wanting to appear dumb, he feigns being able to see it. But his downfall really comes when he parades himself in his finery to all his citizens.

Initially, in spite of seeing nothing but pink flesh before them, they all coo over its magnificence. No one wants to be the apparently lone idiot unable to see it. That is until a child, oblivious to such social pressures, ignores what he is supposed to see and points to the King’s obvious state of exposure. Finally, after a little persistence, the boy’s words sink in and everyone agrees there is no suit and that the king is actually doing a streak!

Today’s players, treading the boards, have not quite reached this final act. In our fable Chloe has been held up as the ideal female role model, the cheering public have acquiesced, blogging rallying cries of ‘go for it girl, you look fantastic’ and the little boy (AKA Monica Grenfell), has bravely pointed out that, rather than looking fantastic, the other ‘f’ word – fat – would be rather more appropriate. Unfortunately, this is where the parallel play has kind of stalled. Where the public should now say: ‘Hey, maybe this Grenfell lass has got something’, they’ve instead reached a crescendo of Chloe worship and savaged our candid whistle blower. Why do they not see what Monica sees? Well for two worrying reasons, which this saga unhappily highlights. Firstly, because obesity is so rife, many people have become blind to it. And secondly, because of those who can see that Chloe is fat, many perversely feel that this is something to be celebrated.

Let’s take the fat deniers first. Their internet postings go heavy on the euphemisms. Fat women become ‘real’ women or ‘curvy’, the modern day spin on ‘big-boned’. Well, I don’t know which thesaurus they are using, but it bears no resemblance to the likes of ‘beefy’ or ‘pudgy’ that I find under ‘fat’ in mine! Now I don’t want to judge poor Chloe on appearances, but she’s put herself in that arena by entering a beauty contest. Surely a prerequisite for beauty should be looking healthy. No one expects the nicotine-stained fingers of a chain smoker to be found attractive, nor the jaundiced complexion of an alcoholic, or the rotten teeth of a bulimic.

Ditto, someone who is overweight and therefore exercises too little and/or eats too much. I’m not advocating size 0, but why not a healthy slim figure with at least a modicum of muscle tone? Bizarrely, according to her stats, at 5’10’’ and 12 stone 8lbs, her BMI comes out at barely overweight. Having seen hoards of patients over the years and giving her bikini shot a good going over, I can’t help thinking that something’s rotten in the state of Denmark, as our thespian friends would say!

However, even giving these stats the benefit of my considerable doubt, it only goes to show how the BMI usually underestimates obesity. Again, fat deniers love to slate this tool, oft quoting the likes of Jonah Lomu and his BMI over 30. Yet, rarely do such dissenters practice any exercise, let alone international rugby. If the BMI is to be criticized, its biggest sin is in underestimating obesity. Indeed, what dietitian hasn’t calculated someone’s BMI to be healthy, only to look up into a moon face peering over a pot belly. With overweight and obesity becoming the norm, it’s no longer the metaphorical elephant in the room, because the room is full of elephants.

Which leaves us with the second, equally worrying category of Chloe supporters: those who recognize her as fat, but who actually want that to be promoted as a healthy alternative body form. Whole groups of such like minded people have bandied together into organizations such as NAAFA, the National Association to Advance Fat Acceptance, ISAA, the International Size Acceptance Association and closer to home, Big People UK.

With banners arguing that obesity is NOT a disease, these groups have stated objectives such as, stopping all research into the treatment of obesity, calling instead for studies into issues such as, the cultural bias against fat people. Try telling a heart struggling to service an obese body it’s just got a bad case of fat prejudice!

When it comes to choosing a beauty queen, just like the models we see when flicking through the glossies, it is healthy role models we need. Not fat, nor emaciated. I don’t buy House and Garden magazine to see photo shoots of a dilapidated old council flat, I want to see something to aspire to, even if I do live in a shabby shoebox.

Likewise, I don’t expect to see Vogue showcasing someone with acne, even though more than the odd pimple has crossed my path. Yes, the average UK woman is a size 16, but surely a beauty contest, any contest isn’t about finding the average, but the exemplary.

People have value, whatever their size, but being fat should never be a selling point.

*A role model for ordinary women? By Monica Grenfell, Daily Mail, Thursday, April 3, 2008