What's truly making us fat?
Calorie counts on menus are looming, joining a bewildering range of diet advice. Is sheer confusion why most of us are overweight? Regina Lavelle reports
Two mystical phenomena mark January. At their worst, both new year horoscopes and fad diets can exemplify a grubby exploitation of the hopeless and vulnerable with the same propensity to spin tiny truths into fool's gold. One offers sweeping predictions of change without regard to science. The other is astrology.
When it comes to the annual avalanche of trendy diets, their guidance can diverge wildly from institutional advice, leaving many bewildered as to what is really true.
For example, a Harvard study published in the British Medical Journal in 2018 suggested that a low-carbohydrate diet (20pc) was more effective than a high-carbohydrate diet (60pc) for burning calories. So should we all ditch carbs entirely? What about those who insist we should only eat inside an eight-hour window to optimise our metabolisms?
The public is being inundated with contradictory messages and advice - carbohydrates are good, carbohydrates are bad, fats are good, fats are bad. On sugar (bad) there is more agreement.
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In such an environment, it's little wonder people get confused; and where there is confusion, there is opportunity to advance unsupported claims against what is portrayed as the staid orthodoxy.
And nothing represents the orthodoxy quite like the food pyramid, an illustration originating in Sweden in the 1970s, and adopted across the world. It was most recently updated in Ireland in 2016. But against the crusade of diet gurus, Instagram bloggers, YouTubers and assorted food-o-maniacs, the gospel of moderation preached by the national nutritional guidelines looks uninspiring by comparison.
The affluent health-conscious ask why it doesn't reflect what's on their plates. Where, they wonder, are the goji berries, the pomegranate seeds, the acai?
Others believe its message doesn't include them, as they would never eat dairy/meat/carbs - delete as applicable.
To judge it solely by its relevance to the lifestyle of the already healthy is to miss the point - the food pyramid addresses two serious national deficiencies which cannot be patched over with health store supplements: the information deficit and expanding weight inequality. According to 2015's Healthy Ireland Survey, 60pc of the population over 15 are either overweight or obese: 37pc overweight, 23pc obese.
Drill into the figures further and social differences emerge. In the country's most deprived areas, one in four is obese, compared to one in six in the least deprived. This is weight inequality, and shortening this gap by 10pc was set by the Government as a five-year target in 2016.
Childhood obesity is a relatively recent phenomenon in this country.
"In 1979, about 1pc of children in Ireland were obese," says Dr Catherine Conlon, director of human health and nutrition at Safefood - an all-Ireland public body responsible for raising consumer awareness about healthy eating and food safety issues.
"Forty years later in 2019, 10pc are obese and about a quarter of them are overweight and obese. Almost two-thirds of adults are overweight and obese, and the high levels again are higher in the lower socio-economic groups. So now only 40pc of the Irish adult population are a healthy weight - one of the biggest public health challenges facing us today."
Those dealing with the public regularly believe that one of the primary drivers of the crisis is an information deficit.
"There's no question people are clueless," says fitness expert and Real Health podcast host Karl Henry. "As a nation, we can't cook. We don't know how to cook anymore. We don't know what's in the food we're eating and we don't know how many calories are in that food. And when the Government tries to educate people about what's in the food, you get pushback, with some people saying they don't need to know. Well they do need to know because it dictates everything."
Call it collective ignorance. Call it wilful intransigence. Call it too much high-fat, high-sugar food targeted at families on low incomes. Call it what you like but the cost is unarguable. The price the Exchequer pays is enormous.
The lifetime costs of childhood obesity have been estimated at €4.52bn.
A 2009 report published by Safefood put the annual costs of excess weight and obesity at €1.13bn, consisting of €398.6m in direct costs (including €234m in drugs), and €728.9m in indirect costs like absenteeism.
The cost is not only monetary of course; the report also noted that conditions associated with excess weight and obesity included Type 2 diabetes, hypertension, heart disease, stroke, congestive cardiac failure. Also cancers of the oesophagus, post-menopausal breast, endometrial, kidney and colorectal. Then there are the disorders one might not associate with being overweight like asthma as well as those more recognisable: osteoarthritis and gout.
In this light, nutritional guidelines might be seen as retail-level information which distils the science to inform the public.
"The purpose is to help the consumer understand the information that's available and to make the best decision for their health," says Dr Conlon.
"Healthy eating guidelines and the food pyramid are developed by an interdisciplinary, multi-stakeholder group. The Department of Health would lead on it with the HSE, Safefood, the FSAI, Irish Nutrition and Dietetics Institute, the Health Research Board. They all coalesce to interpret scientific evidence and translate it into policy.
"This is all feeding into the Healthy Weight For Ireland 2016-2025, which is very much about nutrition guidelines, but specifically about tackling overweight and obesity in an environment where 60pc of adults and 25pc of children are overweight or obese."
The pyramid was updated in 2016, in line with the Healthy Weight For Ireland policy which includes both 'bottom up' and 'top down' approaches including the sugar tax and calories on menus, which have been road-tested internationally. The cost-effectiveness and impact of 74 State-level interventions were explored in a McKinsey Global Institute (MGI) report in 2014, which found that the most efficient were portion control, followed by reformulation (reducing sugar and fat content in products) and then high-calorie food/beverage availability.
Cost of being healthy
It is not only the wealthier population who may find the food pyramid to be divorced from their reality. Personal relevance is an area of difficulty for any national advice, and nutrition is no exception. These guidelines need to be a 'best fit' to do the most good, including for those who are most deprived. It's in these groups that the will to be healthier fights the cost of being healthy.
"We've looked at the census data for Ireland and picked the four commonest households," explains Dr Mary Flynn, chief specialist in public health nutrition at the Food Safety Authority of Ireland (FSAI).
"We made up their diet for a week and costed it in different outlets - a nationwide supermarket, corner stores and discount supermarkets.
"We assumed the families were on social welfare and examined the proportion of their income needed for food.
"We found that families with children were worse off when it came to affordability of healthy eating. We also found that the fruit and vegetable group was the most expensive, followed by the meat group."
But in an obesogenic environment (one that tends to encourage obesity), if we cannot make healthy food affordable - never mind attractive - what hope are guidelines? The Government's policy document certainly hints at more interventions to redress the balance but as we lead ever-busier lives, even for those on good incomes, resisting convenience food such as takeaways is difficult.
This is especially the case for those working long hours in stressful jobs where the desire to eat well butts heads with the necessity to eat quickly. It was when anaesthetic nurse Rebecca Dooley (24), from Kildare, started nursing college that she found juggling shifts with lectures left little time for food preparation.
"I started eating badly - takeaways, chocolate, crisps, jellies, biscuits, loads of carbs. There was no fruit, no veg - no fresh food. I knew I wasn't eating right but I felt it would be a temporary thing," she says.
"When I went into my first full-time job then and went completely out of control and I went up like six, seven stone more than I was at my baseline."
Making the transition into full-time work didn't reduce temptation.
"I would drive home and you would pass all of these takeaways and it was just so easy to pull in and pick one up," says Rebecca. "The temptation is really hard to fight.
"I just was feeling down all the time. I come home from work, I'd eat, then sleep on the couch. Leading up to Christmas 2018, I had started putting off going out. I would pull out of events at the last minute. I was embarrassed and ashamed."
Her mother Anne (53) had also been gaining weight - around three stone in the same period. They both decided to address their issues together and signed up for the local WW (formerly Weight Watchers).
"We were goody-two-shoes when we joined. We were the best pupils," Anne recalls. "The trainer would ask if we had a bad day or a bad week and we never did. We never slipped up. Rebecca was losing four and five pounds every week."
They both reached their goals before summer last year.
Anne and Rebecca both say losing weight is extremely difficult when you are bombarded with messages about food everywhere you look. The Healthy Weight For Ireland document does acknowledge the dichotomy.
"Food and retail outlets are more widely available now than ever before; this becomes important as children have 'discretionary income' and may not follow the healthy eating guidelines," it says.
Even those who do follow a healthy diet may find their weight increasing; this was the case for Terrie Cronin (56) from Co Wexford.
Having always been a size 10-12, she says in her mid-forties she jumped to a size 16. There were additional health complications. Her cholesterol increased to 7.4 and she developed psoriatic arthritis, an autoimmune disease. But she hadn't been eating badly.
"Every morning I would have either breakfast biscuits and fruit or porridge and fruit. At lunchtime I would have a toasted ham and cheese sandwich on brown bread and a bowl of vegetable soup. And then for dinner I would have potatoes, rice or pasta and whatever meat or veg went with that," she recalls.
She knew she had gained weight but had not moved seriously to address it until she saw her GP, who had weighed her.
"He said, 'Terrie, are you doing any walking? Because you need to do something to lose weight'," she recalls. "He was lovely about it. And I trust him emphatically. I was still devastated but it was a total reality check. I really appreciated it because he had my best interests at heart and he's an extremely good doctor. So I went home and started looking at what I could do."
She had tried for some months with various slimming clubs to no effect before she found Elate.ie, a fitness and health programme run by Daniel Meany. Within five months she had lost four stone.
"I didn't increase my protein," she says. "I take 100 grams of protein a day - I would have eaten protein at my breakfast, at lunch, at dinner. So my protein levels did not change. All my carbs went down; my fats went up, my fats went down depending on the challenge that I was doing."
The biggest change, she says, was cutting out sugar. She also says that although she felt she was eating well, according to the guidelines, there are some areas - and sugar is one of them - where the advice needs to be made more explicit.
"The guidelines are useful but it's a lot to navigate. I needed someone to lead me through and support me and help me when I got lost."
There are moves to make the GP framework more proactive when it comes to weight management - especially with additional resources due to come on stream with the introduction of Sláintecare. But are we ready for our weight to become a medical issue?
"Personally, at least half the people I speak to who are overweight are in constructive denial," says Dr Brendan O'Shea of the ICGP (Irish College of General Practitioners) council, and who chairs the Clinical Advisory Group at the HSE/RCSI.
"Partly that's because they've been able to wander in and out of offices run by people like me and we actually haven't mentioned it to them. So going forward, I think we've got to say, 'Look, you're probably not taking enough exercise, and you're definitely eating too much food'."
This isn't an issue solely for those on lower incomes.
"Diet inventories show that even if people are buying from a boutique, organic food store, they can still be overweight. You can have too much good food," says Dr O'Shea. "And that's one of the issues I have with the food pyramid. It's all a little bit relative."
So, say you are overweight. What happens then? Again, there are gaps.
If you're overweight with a BMI of between 25kg/m2 and 30, rather than obese (30 and over), the advice, says the HSE, is to go to a slimming club. (At BMI 30, patients can avail of prescribed drugs to enable their weight loss. At 35 with 'co-morbidities' - illnesses - or at BMI 40, patients are considered for bariatric surgery, although here the provision is again well below comparable jurisdictions.)
Anne, Rebecca and Terrie all sought help privately to address their weight gain, and all were pleased with their results. But these resources cost money, and for those without that wherewithal, there is a question mark.
"If the person has a BMI above 25kg/m2 they should be advised to consider commercial, self-help and community supports, eg Weight Watchers, Unislim and Slimming World, as well as evidence-based online resources such as www.hse.ie/healthyeating, HSE-supported weight management programmes where available, and information from Safefood," a HSE spokesperson said.
They pointed out that there are community support programmes, accessed through "Health and Wellbeing services" but acknowledged that they "will not include a behavioural support component for weight loss". There are initiatives like the Park Run, which some health insurers already recognise and reward.
Healthy Weight For Ireland recognises the absence of provision but stops short of committing further.
"It is recognised, however, that there is a need for greater capacity across the range of overweight and obesity services throughout the community. The need to quality assure weight management services including those provided on a commercial basis is recognised."
There are plenty of gaps to be filled. However, there is progress.
"The problem is still getting worse but there is a sense we're beginning to get traction on it," says Dr O'Shea from the ICGP. "The prevalence of excess weight right across the board is still rising, but we would sense a somewhat lower level and we are getting a better certainty around what we can actually usefully do."
There are government policies which are beginning to have a positive effect. The sugar tax introduced in 2018 led to reformulations of many high-sugar drinks. This meant that by the time of a 2019 Safefood survey, the average amount of sugar per serving in energy drinks had fallen by 8g. As a result, the proportion of energy drinks subject to the higher tax had fallen by 30pc.
Similarly, adding calories to menus, though it agitates the inevitable curmudgeons, is an evidence-based intervention, recognised by the McKinsey research as the most efficient intervention for tackling excess weight.
And it does lead to behaviour change.
"We were involved in publishing calories on menus in a staff canteen in a hospital in an area of Dublin that wasn't a rich area," says Mary Flynn of the FSAI. "We observed customers and kept the menu the same when we added the calories.
"There was uproar when people realised the number of calories in the baked potato - a very large potato was used - so the staff, under duress and under pressure from the consumers, had to change the size of the potato."
There are other options being examined by the agencies involved, including more reformulations. There is also acknowledgement that consumers may need more financial help with healthy food.
Dr Conlon of Safefood is in favour of further taxation on high-fat, high-sugar foods, "also combining that with subsidies on healthy foods".
There is some consensus that the public still needs a bit more stick to prod us to make better decisions. However, in the current absence of a financial carrot, how do you encourage families on low incomes to eat better? This inequality is a vicious circle of information, affluence, culture, and a myriad of other factors.
Karl Henry acknowledges a polarisation.
"People are really very, very fit or very unfit. There's a real extreme vibe now in Ireland. The fit crowd goes to the gym every day all the time. Then there's the other end of the spectrum where we need the intervention from the likes of Safefood," he says. "I firmly believe people want to be healthier, but I also firmly believe that they don't know how."
Ireland's weight inequality may need financial and political initiatives to succeed but it starts with the information gap. Bad nutrition information isn't a victimless crime.
'Modern Culture and Wellbeing: Towards a Sustainable Future' by Dr Catherine Conlon is out now, published by Veritas