Does fat deserve a retrial?

Why defenders are fighting to clear the reputation of a nutrient they say has been unfairly blamed for the obesity epidemic. By Nick Hughes.

As sugar begins a long sentence for its role in the obesity epidemic a campaign is being waged to get another convicted nutrient off the hook.

Fat has long been cast as public enemy number one where diet-related ill health is concerned, not just in the UK but across most of the developed world. Yet murmurs of disagreement that have been audible ever since “low fat” and “lower cholesterol” messages first made their way into UK public health advice in 1983 have recently turned into roars of opprobrium from those who claim a catastrophic miscarriage of justice has taken place.

Defenders of fat argue that decades of government advice to reduce consumption has had disastrous health consequences. They note that obesity rates have soared in the years since fat became ostracised; a result, they claim, of increased consumption of low-fat junk foods, refined carbohydrates and polyunsaturated vegetable oils.

Emboldened by NHS data which shows that obesity rates increased from 15% in 1993 to 27% in 2015 – a period characterised by rapid development of low-fat convenient food options – the pro-fat movement has formed a charity to ensure its message is received loud and clear.

The Public Health Collaboration is supported by a number of dieticians, cardiologists and GPs who subscribe to the view that the key to tackling obesity is to reduce consumption of processed foods, notably refined carbohydrates, and eat predominantly natural and nutritious foods, such as meat, fish, eggs, nuts, seeds, olives and avocados, all of which contain saturated fat.

The group hit the headlines last year when its incendiary report – “Eat Fat, Cut The Carbs and Avoid Snacking To Reverse Obesity and Type 2 Diabetes” – prompted sensationalist newspaper headlines such as “Get fat to get fit” and “Eat more fat to stay healthy”. Since then, the public health community has been in a permanent state of civil war.

Public Health England (PHE) told Footprint that calls to eat more fat and reduce consumption of carbohydrates were “irresponsible” and noted that international health organisations were in agreement that too much saturated fat raised cholesterol, increasing the risk of heart disease, and obesity was caused by consistently consuming too many calories.

The debate will continue to rage within the public health community, but the implications go far beyond the point-scoring of a small group of scientists and medical professionals. For starters, what should the public make of the barrage of mixed messages on what they should eat to stay healthy? And how should food businesses balance the need to adhere to government dietary guidelines with responding to the changing demands of consumers?

“It’s a terrible situation that we’ve got,” admitted Sam Feltham, the founder and director of the Public Health Collaboration. “The one thing I would say is the only confusion is the fact that we’ve recommended that people restrict total fat and saturated fat in the first place based on no evidence.”

Feltham’s point about the evidence base for reducing fat consumption is a source of huge contention. Supporters of the Public Health Collaboration point to systematic reviews of the evidence, such as those authored by obesity researcher Zoë Harcome, that suggest the results of scientific trials did not support the introduction of dietary fat guidelines in the US in 1977 and the UK in 1983.

Writing in the British Medical Journal in 2013, the high-profile London-based cardiologist Aseem Malhotra argued that while scientists universally accept that trans fats – found in many fast foods, bakery products and margarines – increase the risk of cardiovascular disease, saturated fats have been demonised in dietary advice since studies that concluded a correlation existed between the incidence of heart disease and saturated fat consumption had failed to prove causation.

PHE rejected this analysis and stated there was good evidence from randomised controlled trials that saturated fat consumption influenced cholesterol levels and increased the risk of cardiovascular disease.

Another (rare) point on which both parties agree is the link between excessive sugar consumption and the heightened risk of obesity and type 2 diabetes. Sugar has long been used as a replacement for fat in processed foods and Feltham is keen to highlight its prevalence in refined carbohydrates. Yet when the government’s Scientific Advisory Committee on Nutrition (SACN) reviewed the evidence on the role of carbohydrates in dietary health two years ago, it found no evidence to alter existing advice that 50% of total dietary energy intake should come from carbohydrates, despite recommending that average sugar intake should be reduced from 10% to no more than 5% of energy. The recently updated Eatwell Guide, meanwhile, maintains the advice that no more than 10% of daily calories should be consumed as saturated fat.

PHE admitted that “it’s difficult for the public when every day the media have a story on the latest fad diet or must-eat superfood”, but added that the key to maintaining a healthy weight was “about consuming a varied diet in keeping with the government’s advice”.

If only it were that simple. Eretia O’Kennedy is a freelance nutrition consultant and former head of nutrition at the Jamie Oliver Group. She supports the government’s existing advice and believes the row over the role of fat in the diet is an unwelcome distraction. “When you look at the bigger picture, most of us aren’t even meeting the government recommendations, so let’s focus on that first before we try to change them,” she said.

As for businesses, O’Kennedy said they should focus first on giving choice to the customer and trying to nudge them towards healthier options. She also advised that chefs should look to include all of the five food groups – carbohydrates, protein, dairy, fruit and vegetables, and fat – in dishes rather than focus on individual nutrients since “people don’t eat nutrients, they eat food”.

The fat debate is particularly pertinent for contract caterers whose dishes must adhere to government buying standards if they wish to compete for a range of public-sector contracts. If the “fat is good” message starts resonating with the public, businesses will have to decide whether to rigidly follow government guidelines or respond to consumer demand.

“I do appreciate how hard it’s going to be for businesses and caterers if they’re bidding for these contracts,” said Feltham. “We’d encourage them to go down the lines of real food as much as they can but also hopefully we will be able to change the dietary guidelines for the better.”

The ultimate goal of the Public Health Collaboration is to change government dietary advice to incorporate more “real food”, as Feltham put it. In the meantime, it plans to bypass the Eatwell Guide by speaking directly to the public. “We’re doing it from the ground up – trying to spread this information to the public as much as possible,” said Feltham, who claimed that healthcare professionals within the NHS were using the charity’s advice rather than government advice and were getting better results as a consequence.

PHE said it was keeping a watching brief on emerging evidence on fat and noted that the SACN was reviewing the most up-to-date evidence on the relationship between saturated fat and health.

A draft report is expected to be published for public consultation in late 2017. If it comes out on the side of fat, more than 40 years of nutritional charges against a single nutrient could be thrown out in a stroke. If the verdict remains the same, don’t expect the defendant’s supporters to go quietly into the night.

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