Thursday, 29 March 2018

The Pioppi Diet and the mysterious disappearing women

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.

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).

Sunday, 28 January 2018

Sugar in the news

Over the last week, I've been conducting searches via the newspaper archive, LexisNexis, to create a  database of UK newspaper articles addressing the topic of sugar*. The aim of the exercise was to compile a dataset of texts (newspaper articles) which will be subject to a detailed critical discourse analysis, but in the first instance, it was also a chance to confirm the recent and dramatic rise of sugar in popular discourse - something which I have been asserting but wasn't able to demonstrate until now:

As you can see, coverage of sugar is steadily minimal until 2012/ 2013 (in spite of the fact that the 'war on obesity' raged fiercely throughout the first decade of the 21st century), after which it rises precipitously over just a few years. In spite of the modest drop in 2017, I anticipate a significant jump upwards again in 2018, which has already seen widespread reporting of the launch of the Change4Life campaign against sugary snacks, various interventions banning the sales of energy drinks to children, Tameside hospital's move to ban the sale of sugary foods as a response to staff obesity and calls for taxation of 'sharing' bags of chocolate. In part, this reflects a typical January pattern of anti-sugar, 'new you' reporting, but in the year when the 'sugar tax' will be introduced, I anticipate a lively news year for all things 'sugar'. 

I'm now in the process of breaking the distribution of articles down into months, focusing on 2013-2017, and matching flurries of reporting with the key policy announcements and research publications (e.g. sugar tax announcements, the launch of the Change4Life Sugar Smart app, the 2015 launch of the Public Health England report on sugar reduction). These announcements, reports and research publications, as well as industry responses (press releases, marketing campaigns etc) will also be added to my dataset and analysed in dialogue with the media reports in order to explore the multiple discourses, practices and interests at work in the social life of sugar. And in doing so, I will also be asking: what is rendered invisible in those debates, what questions go unasked, and whose voices are heard / unheard? 

More to follow as I start to work my way through the data. 

*A word about methodology:
I tried numerous combinations of search terms, but in the end, settled for the simple strategy of searching for "sugar" in the article title in a given year in the following UK newspapers: The Guardian, the Observer, the Times and Sunday Times, the Daily Telegraph and the Sunday Telegraph, the Sun, and the Mail and Mail on Sunday. The initial lists of articles were then edited for relevance. For example, I removed all the recipes (which make up the bulk of December sugar reporting), articles about 'sugar daddies' (a discussion for another time), and the astonishing number of articles about Alan Sugar. I also removed all business stories (although I may return to this later) and excluded readers' letters, primarily in the interests of keeping the dataset within manageable limits. I also removed a number of articles using a range of sugar puns and metaphors (sugaring the pill, a spoonful of sugar) to headline stories but which weren't about sugar. This left me with a core dataset of approximately 400 articles (2013-17) for analysis, all circulating around the 'problem' of sugar as a (contested) threat to health and as a site of necessary and often urgent intervention. 

Monday, 22 January 2018

But you're not defending sugar, are you?

When people find out that I'm researching sugar, the first assumption is that I'm joining in the attack on sugar - perhaps by finding out how sugar consumption can be reduced, or exposing the nefarious workings of the sugar industry. When I tell people that I'm not attacking (or endorsing) sugar, and  certainly have no intention of concluding what people should or shouldn't eat, there's a momentary pause, and the puzzled, slightly disappointed question: "But you're not defending sugar, are you?"

Firstly, I'm pretty sure that sugar doesn't need defending. In spite of its currently demonised state, demand for sugar is alive and well, and so-called 'big sugar' and its associated industries remain a powerful lobbying force. Having said that, I'm half tempted to try something along the lines of what French Literature professor, Richard Klein, describes as 'contrarian hyperbole', arguing that "when anything has been so debased or so glorified that its value is taken for granted, it becomes rhetorically necessary exaggerate the value of its opposite in order for skepticism to be heard at all". He brought this to bear beautifully in his books, Cigarettes and Sublime, and Eat Fat, but I'm not sure that I can carry this off with the same aplomb...Although the presumption of indefensibility makes me want to try. But in any case, this wouldn't constitute a 'defence' of sugar so much as a means of opening up the discussion. Which leads me to my second point...

I want to move away from polarising debates about the toxicity and over-consumption of sugar, and certainly want to distance myself from efforts to persuade or coerce (targeted) people to eat in normatively endorsed ways. I want to suggest that the attack on sugar is not about sugar per se - for example as a foodstuff of disputed nutritional value - but rather, I'm beginning from the premise that the prevailing discourse of sugar as 'public enemy number one' is functioning to obscure and silence dissenting voices while neutralising troubling social processes: for example, the normalisation of fat-phobia, the naturalisation of social inequalities, and the assertion of the primacy of 'health' as a marker of good citizenship. The project, then, aims to explore not how much sugar people should eat, but rather, what is silenced by the attack on sugar and what is brought to the fore. What goes missing in the rush to blame sugar and what is given centre stage? And to what intended and unintended effects?

This is my challenge - to find a way to think about sugar that makes me neither an apologist nor an anti-sugar warrior, but rather, which enables me to enact a thoughtful pause; to refuse the rush to "do something" that characterises anti-sugar discourse and practice to create spaces where we can explore wider questions of social inequality, food and environmental justice and embodied diversity.

Wednesday, 29 November 2017

The unseen hazards of researching sugar

Welcome to my new blog - Sugar Rush. Thanks for visiting.

I'm already 3 months into my fellowship and it's already becoming increasingly clear that it is going to be impossible to write about sugar without writing about the intense fat-phobia that travels hand-in-hand with anti-sugar campaigning. I'm still not at all certain how to untangle it all, but I'm experiencing a growing discomfort with the aggressive treatment of fat bodies that I am encountering in the attack on sugar. I wrote this short post about the personal challenges of researching sugar for the Centre for Interdisciplinary Gender Studies (CIGS) blog, and I've reproduced this below. It seems like a bit of a negative opening for the Sugar Rush blog, but I suspect that this is going to be a recurring and important theme that I'll continue to develop as the project progresses. And it's not all negative either, thanks to the restorative powers of feminism.


A few weeks ago, as part of my ongoing research on the social life of sugar, I set myself the task of watching a series of anti-sugar, and by extension, anti-obesity, documentary films. How do they tell the story of sugar in contemporary society? What evidence do they draw on? What imagery do they use? Who are the authoritative voices of anti-sugar? How do gender, race and class figure in those narratives?
Over just a few days, I watched Cereal Killers, Run on Fat, The Big Fat Fix, Fed UpWhat the Health, and Carb-Loaded. I watched each one twice; the first viewing was to get a general sense of the film, and during the second, I took detailed notes. It sounds leisurely and entertaining to watch films for research, but by the time I got to What the Health – an anti-sugar, anti-dairy documentary promoting a whole-food, plant-based (WFPB) diet – I started to feel inescapably sad at the overwhelming fat-hatred that runs through the films. I took stock and revisited my notes. They recorded over and over again the use of what fat activist, Charlotte Cooper calls the ‘headless fatty’ images – fat, headless torsos, thighs or backsides, often with hands clutching packages of fast food, from which we are supposed to deduce a lifetime of poor choices and devastatingly expensive health problems. A parade of ‘experts’ – predominantly white, male, middle class professionals – proclaim the catastrophe of the fat body, and especially in the case of children. In Fed Up, we meet 12 year old Maggie, who cries in despair and shame because she hasn’t lost any weight. Only her body size matters to the filmmakers, and the commentary ignores how articulate she is, how insightful, or how much fun we see her having in clips of her swimming and kayaking with her friends. These ‘failed’ bodies are contrasted with the ‘good’ bodies of predominantly male athletes whose lean, able-bodied physicality signal the normative self-control of the disciplined subject. None of the films talk about the constraining effects and pressing demands of poverty, or the gendered labour of shopping for and preparing the fresh, whole food they recommended.
The fat-phobia of the films started to weigh heavily on me. The films are hate narratives parading as entertainment and they are stained with contempt for the fat body. I felt poisoned by them, and in spite of my very critical understanding of fatness, I had inadvertently made myself a target of their fat hatred simply by virtue of watching the films. It was dispiriting; a concentrated encounter with the hatred that the visibly fat encounter every day, and one that brought my enthusiasm for my new project temporarily to a grinding halt.
So what’s a researcher to do? Clearly, leaving the films unwatched and unexamined is not an option, so instead, I instigated an anti-sugar film self-care regime. The first step was to abandon my binge-watching strategy and pack away the films; I took a whole week off from watching and instead burrowed my way through a pile of feminist technoscience studies gems that restored my faith in the world and in my research. The second step was to move to a schedule of no more than one film per week; and then finally, to follow each film immediately with a book of such incisive and feminist potency that the fat-phobic stain simply couldn’t withstand its force. The take away lessons from this experience are: (1) pace yourself, especially with potentially upsetting material; and (2) never underestimate the restorative power of feminist literature.