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"I'm really confused, doc. I now know sugar is bad, but with all these newspaper stories I don't know what else to eat. Is cutting carbs a fad, or should I just count calories and stick to a low-fat diet?"

In 2013, following months of research analysing the latest scientific literature on the harms of excess sugar consumption, I published a commentary in the British Medical Journal entitled, "The Dietary Advice on Added Sugar is in Need of Emergency Surgery."

I called on the Government's Scientific Advisory Committee on Nutrition (SACN) to urgently revise guidelines that had, in effect, been advising the UK population to consume 22 and a half teaspoons of sugar a day as part of their "Guideline Daily Amount [GDA]". This was despite the fact that a consensus statement paper from the American Heart Association in 2009 had recommended a maximum daily limit for added sugar of nine teaspoons a day for men and six teaspoons for women.

To put this in perspective, a can of Coca-Cola contains almost nine teaspoons of added sugar - which they said represented 39 per cent of the GDA. What's more, a regular sized Mars Bar contains almost triple what the US Department of Agriculture had recommended to be the maximum limit for the average four to eight year-old child.

It had become clear to me that commercial relationships with food companies that profited from the sale of sugar with organisations and charities were hindering dietary advice based upon the up-to-date evidence.

On their food fact sheet, The British Dietetic Association (BDA) stated that sugar was only harmful to teeth while flatly denying that eating too much sugar caused type 2 diabetes.

In an email exchange, their head of communications, Jo Lewis, told obesity researcher Dr Zoe Harcombe that the BDA had been "delighted to work with the Sugar Bureau."

At the same time, Diabetes UK, whose corporate partners included Abbott, parent company of Abbott Nutrition, were equally in denial regarding the dangers of sugar consumption and the effects it had on type 2 diabetes. Due to its excessive sugar content, its formula milk products had been implicated by respected Californian Paediatrician Robert Lustig in infant obesity - a 240ml serving of Abbott PediaSure fortified milk (which is marketed for one to three year olds) contained just over eight tea spoons of added sugar.

In 2012, Abbott nutrition had declared financial support for conference exhibition fees and sponsorship for Diabetes UK, equalling £44,302. It was instructive to note that Diabetes UK's website stated "Partnerships [with corporates] are tailored to meet their corporate objectives," and that "this approach guarantees mutually beneficial outcomes."

The article received good publicity including a prime-time slot with me being interviewed about it on BBC Breakfast.


After the interview Bill Turnbull, the show's presenter, told me that it was "very telling" that none of the 10 different companies or organisations associated with carbonated beverages, supermarkets and sugar manufacturers were available to discuss my concerns on the sofa.

Less than a year later, The Sunday Times and Channel 4 Dispatches exposed that several members of SACN had received considerable research funding and personal fees from confectionary giants with its Chairman Professor Ian McDonald working as a paid advisor to Coca-Cola and Mars.

In a pertinent editorial in the Daily Mail it was pointed out that "if they [SACN] enjoy such sweet business connections, can we trust the advice our scientists give us on diet and obesity?"

Such widespread media publicity, including many obesity campaigners joining forces to agree that sugar was now enemy number one in the western diet, appeared to have a significant impact.

Within months, the World Health Organisation revised its guidelines suggesting that the maximum daily limit of sugar consumption should make up no more that five per cent of calories, equivalent to six teaspoons of sugar a day.

But despite several years' worth of data highlighting the harms of excess sugar consumption, why did it take so long for significant action?

Science alone isn't enough

As documented by Yale's Professor Kelly Brownell and Kenneth Warner from the University of Michigan, the history of the tobacco industry's dirty tricks to hinder effective interventions to reduce smoking is a powerful lesson, which proves that the science alone isn't sufficient. Opposition from vested interests needs to be overcome if we are truly going to make inroads into tackling lifestyle related chronic diseases that are crippling health systems around the globe.

In 1952, the Reader's Digest - at that time the public's most trusted source of medical information - printed an article entitled "Cancer by the Carton". For almost two years afterwards cigarette sales plummeted, the first significant decline in sales since the Great Depression.

Just over one year later, in an effort to curb the damage caused by studies that linked smoking and lung cancer, Big Tobacco paid for a statement to be printed in 448 newspapers promising to make more effort and work closely with "those whose task it is to safeguard the public's health", assuring Americans "we accept as a basic responsibility, paramount to every other consideration in our business."

What they subsequently did for almost five decades was adopt a corporate playbook that stalled any effective regulation by denying that cigarettes were harmful, planting doubt, confusing the public and even buying the loyalty of scientists. Even as late on as 1994, the CEOs of every major tobacco firm went in front of US congress and swore under oath that they did not believe that nicotine was addictive or smoking caused lung cancer.

Ultimately, it wasn't the illusion of personal responsibility (which requires the correct knowledge and choice) but policy changes that specifically addressed the acceptability, availability and affordability of tobacco that induced the biggest decline in consumption of cigarettes - now accepted to be the single most important factor in reducing death rates from heart attacks in the past three decades.

From my own research it was clear that lifestyle changes on health were huge, something I would see regularly in my own patients who had observed rapid improvements in health markers within days/weeks of ignoring government advice on what constitutes a healthy diet.

Recently, I saw a patient who had been diagnosed with type 2 diabetes almost 10 years ago. Some time back he read an article that I had written for Men's Health about the truth on fat and sugar. Almost immediately, he decided to ignore the advice given to him by his dietitian who said he must put starchy carbohydrates at the base of his diet. As a result, he cut out bread, pasta, rice, sugar and potatoes, and stopped fearing saturated fat. Even he couldn't believe the amount of weight he was losing and was amazed that he was able to come off his type 2 diabetes medication and even reduce the amount of blood pressure pills he was taking.

After my own realisation of the lifestyle misinformation mess, and in an effort to keep the messaging free from any commercial influence, myself and former international athlete Donal O'Neill created a documentary film funded by the public for the public. With the help of Men's Health and The New York Times we were able to raise £50,000 in four weeks, through crowdfunding.

The aim of the film wasn't just to empower individuals and doctors with a lifestyle prescription but also to influence policymakers. That's why we were delighted that it premiered in the UK parliament and had a subsequent screening in the European parliament.

A book we recently published based on the documentary, The Pioppi Diet, is packed with up-to-date scientific references and busts many myths prevalent in today's medical, nutrition and exercise industries but also adopts a more holistic approach, providing a lifestyle prescription.

The dietary plan was reviewed and supported by three internationally respected dieticians, Dr Caryn Zinn, Dr Trudi Deakin and nutritionist Dale Pinnock, all of whom were specifically chosen for their academic prowess and freedom from food industry influence.

The plan prioritises foods that are nutritious, satiating and enjoyable but also incorporates - at their base - specific foods that have been consistently demonstrated in high quality research trials to be most beneficial to cardiovascular health.

Specifically: a handful of nuts, daily, two to four table spoons of extra virgin olive oil, oily fish, lots of vegetables, some fruit, avoiding industrial seed oils and, for the first 21 days, cutting out any high glycaemic carbohydrates and all added sugar.

But crucially, beyond the food plan, we emphasise the importance of incorporating mindful movement, the necessity of getting a good sleep and even the significant impact of stress reduction - just three months of stress reduction combined with diet and exercise has been shown in pilot studies to influence genes that affect the ageing process.

Don't blame saturated fats

In 2017, I co-authored one of the most read pieces of research that year. In addition to completely exonerating the consumption of dietary saturated fat in heart disease, the paper, which was published in the British Journal of Sports Medicine, also revealed that the condition, which is still the number one killer in the western world, could be both prevented and treated by these simple lifestyle changes.

This is because they directly address the two overlapping root causes of the development of coronary artery disease: insulin resistance (a pre-cursor to type 2 diabetes) and chronic inflammation.

As for saturated fat, award-winning science journalist Gary Taubes recently also pointed out that "saturated fat would easily be acquitted" as the culprit for the development of heart disease, and an unbiased judge would possibly even "throw it out of court."

The root of the flawed dietary advice on saturated fat and arguably a root cause of the obesity epidemic has been recently well documented.

It was American scientist Ancel Keys, made famous through his Seven Countries study, published in 1978, that sanctified high cholesterol with the development of heart disease which he linked to saturated fat consumption from foods such as butter, cheese and meat. But correlation doesn't mean causation.

A contemporary of Keys, British Nutritionist John Yudkin, claimed it was not the consumption of saturated fat but sugar that was responsible for the marked rise in coronary heart disease in the first half of the twentieth century. The sugar and processed food industries used various methods to impede Yudkin's work, including interfering with his research funding and publication. Keys publicly attacked Yudkin, using rancorous language to criticise his research. The industry successfully discredited the case against sugar and his warnings were no longer taken seriously.

Interestingly, it's noted in Nina Teicholz's New York Times best-selling book, The Big Fat Surprise, when one of the lead authors of the Seven Countries went back to re-analyse the data, it was actually sugar that correlated most with coronary heart disease deaths, not saturated fat.

In 1987, almost a decade after the Seven Countries study was published, Keys later told the New York Times, "I've come to think that cholesterol is not as important as we used to think it was."

But it was too late. A multi-million-dollar food and drug industry had started to profit from the fear of saturated fat and cholesterol.

Has the statin ship sailed?

By 2020, revenues from the sale of statin drugs are estimated to reach $1 trillion despite the fact that most who take them are not at high risk of heart disease. Many won't receive a single day increase in life expectancy from the drug. What's more, for the overwhelming majority of the population, "high cholesterol" is not a risk factor for heart disease and is actually protective against an early death in those aged over 60.

Establishment and industry orchestrated attacks by those who challenge the status quo with a primary motivation to improve health and ensure that policy and dietary advice reflects the science is very much alive and kicking.

In Australia, orthopaedic surgeon Gary Fettke was banned for life by the Australian Health Practitioner Regulatory Agency from giving dietary advice to help reverse type 2 diabetes in his patients following an anonymous complaint by a hospital dietitian about him "encouraging patients to reduce their sugar intake". This is despite the fact that two thirds of his patients with joint issues were overweight and or suffering from type 2 diabetes.

Fettke himself, who has publicly campaigned to improve the state of hospital food, felt he was clearly targeted - there had been no patient complaint.

After Teicholz wrote a devastating critique in the BMJ, highlighting the US Dietary Guidelines Committee's failing to be systematic in their review of evidence on saturated fat and the benefits of a low carbohydrate diet for their 2015 guidelines, more than 180 academics called for immediate retraction. It later turned out that many of the people signing the letter hadn't even read the article.

In his BBC 1 series, Doctor in The House, GP Dr Rangan Chatterjee's low carbohydrate diet that excluded fruit for those with type 2 diabetes was called by the BDA on their website as "potentially dangerous". This is despite providing no evidence to support their claim.

Dr Chatterjee had revealed with one of his patients, Lottie, in the programme that type 2 diabetes could be reversed within 30 days of diagnosis.

The BDA further stated on their website that "Dietitians are the only qualified health professionals that specifically assess, diagnose and treat diet and nutrition problems at an individual and wider public health level. Uniquely, dietitians use the most up to date research on food, health and disease."

But is this true?

Most recently, The BDA, reported as a "top authority" by Business Insider, described The Pioppi Diet as one to avoid in 2018 with Sian Porter of the BDA making a number of misappropriated and factually incorrect statements. She told BBC News that the book was arguing a case for eating a high level of saturated fat when it does nothing of the sort. She then compounded her error by stating that evidence we had used exonerating saturated fat had been "cherry picked rather than looking at it in its entirety," which is also false.

The book reflected the totality of data using systematic reviews, which revealed no association with saturated fat consumption and the development of heart disease or premature death for healthy people. The book also went on to show that those with heart disease gained no benefit from reducing their saturated fat intake - a conclusion also pointed out in the British Journal of Sports Medicine.

A third error was made by the director of the BDA, Duane Mellor. Writing in the Spectator, he said that our claim that one could drastically reduce the risk of type 2 diabetes and heart disease within 21 days was "not evidenced."

Such assertions only expose their scientific incompetence and ignorance of a multitude of real world and published data, which clearly shows how simple dietary changes rapidly influence markers of cardiovascular risk.

In a recent study of 43 Latino and African American children with metabolic syndrome, for example, keeping total and calories from carbohydrate identical, a reduction from a mean of 28 per cent of calories from added sugar to 10 per cent, significantly reduced triglycerides, LDL-Cholesterol, blood pressure and fasting insulin within just ten days.

It's been this very reliance on eminence trumping independent evidence that often stops policymakers, doctors and journalists asking the right questions while simultaneously misinforming the public.

As Albert Einstein once said, "A foolish faith in authority is the worst enemy of truth."

The public must also realise that the overwhelming majority of dietitians have no qualification or understanding of the basics of medicine and although most doctors equally have little or no training in nutrition, it's not rocket science to advise people to avoid eating processed food, more than 70 per cent of which now includes added sugar.

Sadly, the BDA's case is certainly not helped by the fact that their corporate members include Abbott Nutrition, and the BDA's homepage promotes "Nestle Health Science", two companies that have strong associations with sugary products.

My own Twitter survey revealed 78 per cent of 1,742 respondents felt the BDA could not be trusted as an independent source of dietary advice.

Modern medicine

Modern medicine is also going through a major crisis of trust because of perceived industry influence of science. A published report in June from the Academy of Medical Sciences highlighted more than 80 per cent of GPs don't trust drug company sponsored research. Two in three members of the public feel the same.

This comes less than two years after the editor of the Lancet published an online editorial stating that half the published medical literature may simply be untrue. A few months ago, professor of medicine and statistics at Stanford, John Ionnidis, published a devastating critique on the state of modern medical research with one major analysis revealing only 7 per cent of studies published fulfilled criteria for having high quality methods and being relevant to patients.

As one of the most authoritative independent experts in research methodology, Cochrane researcher and former director of its branch in Bahrain, Professor Zbys Fedorowicz, told me many academics including those from the most prestigious institutions are "gullible, fallible and culpable" when it comes to health information.

Thankfully, cherry-picking of data, designed to benefit private profit over public health, is starting to become more and more scrutinised by the press, savvy bloggers and courageous journalists.

In September 2016, a review of internal sugar industry documents, published in JAMA Internal Medicine, revealed that the Sugar Research Foundation paid three influential Harvard scientists the equivalent of $50,000 dollars each to publish a review in the New England Journal of Medicine in 1967 to downplay the role of sugar in heart disease and shift the blame to saturated fat.

An investigation by health journalist Anahad O'Connor - which made front page of the New York Times - exposed that Coca-Cola were funding scientists to shift the blame for obesity away from bad diets to a lack of exercise. Although none of us can argue against the tremendous health benefits of regular activity over the last 30 years, there has been little change in average physical activity levels in the western world, which only goes to highlight the impact a bad diet has on one's health.

Progress

Over the past few years there's been significant progress highlighting and publicising research that concludes the adverse effects of excess sugar consumption are independent of weight - and thus its consumption should be regulated by governments.

But the message that restricting calories without concentrating on where they come from is the solution to tackling type 2 diabetes, perpetuating the myth that obesity causes type 2 diabetes (and that the primary focus should be weightloss) remains very much alive.

Last month, a high-profile study - described by one of its authors as a watershed moment - made the headlines, stating that type 2 diabetes could be "reversed" from a low-calorie diet. Its lead researcher told BBC News "that weight loss of 10-15kg is enough to turn the disease around". An impressive 46 per cent of the 149 participants with varying degrees of weight loss were able to send their type 2 diabetes into remission within a year, prompting the director of research of Diabetes UK, who funded the study, to say the "trial has the potential to transform the lives of millions of people."

But the elephant in the room was not mentioned anywhere in the reporting.

It's been known for a long time from many published studies that as far as the management of type 2 diabetes in concerned, significant improvements in blood glucose and sending type 2 diabetes into remission can be achieved by following a low carbohydrate real food diet without calorie restriction.

As pioneering biochemist Richard Feinman points out in his own critical review in nutrition in 2015, clinical comparisons of calorie restriction versus adopting a low carbohydrate diet reveal that although "starvation" does improve markers of blood glucose control, it is significantly outperformed by a low carbohydrate, ketogenic diet. This is crucial because up to a third of those with type 2 diabetes have a normal BMI.

With greatest respect to the authors of the Lancet study, the claim that this was a "watershed" moment in sending type 2 diabetes into remission from calorie restriction is akin to ignoring the existence of Usain Bolt and publicising the great speed and agility of another sprinter who doesn't even come close in a head to head challenge.

Diabetes.co.uk, a site I recommend many of my own patients to go to, has already managed to save close to £7millon of NHS money just by advising people to cut down on added sugar and refined carbohydrates. A structured 10-week online programme has already proved very successful, sending thousands of patients into remission for type 2 diabetes within a year.

Final word

So, where do we go from here?

A systematic review of all randomised controlled trials comparing low fat (synonymous with low calorie) with low carbohydrate approaches for type 2 diabetes and important health markers, including those linked to heart disease and quality of life, is currently underway and the results will be published in the next few months. It is being conducted by the most eminent Cochrane academics in the fields of research methodology, Zbys Fedorowicz, Esther Van Zuuren and Professor of Diabetes at Leiden University Hanno Pijl.

Not only will they make direct comparisons but there will also be a review of the quality of the research methods in all the clinical trials.

This will determine what the optimum dietary approach is for most people with type 2 diabetes and help give us the final answer to inform policy makers, doctors and the public of the best ways to help tackle a condition affecting hundreds of millions globally and the single most costly condition to the NHS.

Whatever the outcome, the history of public health advocacy has taught us that the science alone is not sufficient in improving population health and opposition from powerful vested interests needs to be overcome. But one thing is clear: that a diet free from processed food combined with regular activity, getting a good sleep, reducing stress and a strong sense of community could hold the secrets to a healthier and happier life.