June 13, 2016

expert reaction to editorial on the revised UK Eatwell Plate

An opinion piece published in the British Journal of Sports Medicine has argued that the Eatwell Plate, which is based on the government’s dietary advice, does not serve public health.

Victoria Taylor, Senior Dietitian at the British Heart Foundation, said:

“The Eatwell Guide is a tool which is used to illustrate UK guidance on diet for the general population. The guidelines are developed after a rigorous and independent process of review of the best evidence available by the scientific advisory committee on nutrition.

“These reviews take into account a range of different types of research which is necessary when making recommendations for such a complex area as nutrition. Randomised controlled trials alone won’t give us a full picture as carefully controlling the diets of thousands of people over many years would be impossible.

“There seems to be constant criticism of guidelines on nutrition at the moment but the bottom line is that guidelines are meaningless if they are not put into practice. As a nation we know that we still have a way to go before we achieve this.”

Catherine Collins, Principal Dietitian, London Teaching Hospital, and Spokesperson for The British Dietetic Association, said:

“The UK Eatwell Guide continued the ‘plate model’ approach of previous UK healthy eating guides but with some differences. Foods not considered to be part of a healthy diet are relegated ‘off plate’ to a corner slot and additional information on hydration and front-of-pack food labelling, both absent from previous guides, have been added.

“Since publication the guide has raised valid concerns about its appearance and recommendations, some of which are addressed in Harcombe’s BJSM editorial. Replacing photographs with poor quality drawings makes the Eatwell Guide less visually attractive, and the ‘6-8 a day’ drinks advice panders to populism rather than science. Highlighting part-substitution of animal protein for plant based proteins without factoring protein quality is also a valid criticism, given our ageing population and reduction in protein utilisation with advancing age.

“It is unfortunate then that Harcombe’s editorial drifts into her more familiar territory of carb demonization, attempting to interpret the guidelines to support personal opinion.  Her ‘back of envelope’ calculations¹ (her admission, not mine) as to the relative proportion of calories derived from dietary carbohydrates are pure junk science, creating factoids to be exploited alongside other nutritional myths. Attempting to translate food group proportions into actual food weights is a notional maths lesson, not nutritional science.

“Harcombe has created a table of calorific levels for each food segment, but the ranges in calories for each food within a segment are so large as to make this a meaningless maths exercise. For example, she suggests dairy and alternatives provide an estimated 157 kcal per 100g. Yet semi-skimmed milk provides 46 kcal per 100g and cheddar cheese delivers 412 kcal per 100g. Assuming an average value of 43 kcals per 100g for fruits and vegetables highlights the flaws in this oversimplistic approach – there’s over 130 kcal per 100g difference between broccoli at 31 kcal per 100g and avocado 160 kcal per 100g. In any case, reducing calorie intake predictions to values expressed per 100g are irrelevant – people eat portions, not 100g servings.

“Harcombe’s concern that fruit and veg make up a mere 8-9% of energy contribution misses the point entirely. Fruit and veg have relatively few calories, so one still needs to eat a lot of them (with the exception of avocado) to contribute significantly to calorie intake. The Eatwell Guide recommendations on fruit and vegetables were modelled on, and achieve, the 400g minimum daily recommended by the World Health Organisation and governments worldwide.

“It’s worth noting that the recommendations for the starchy food section were modelled from the Scientific Advisory Committee on Nutrition (SACN) report guidelines to provide 30g fibre daily, given the benefit to health of including dietary wholegrains on digestive and metabolic health, these benefits do not appear transferable to other food groups, such as fruit and vegetables.

“Ignored from Harcombe’s editorial attempt to yet again undermine carbohydrates as part of a healthful diet, but relevant to her calorie concerns, is the complete omission of alcohol from the pictorial guide, despite National Diet and Nutrition Surveys (NDNS) data confirming alcohol providing over 8% of daily calories intake in consumers. It is unclear why such an obvious omission be made from this new guide.

“Finally, Harcombe’s assertion that the updated guide was influenced by the food business affiliations of the expert group is ludicrous. From meeting minutes online, the ‘expert group’ appear to have met four times between the preliminary SACN Carbohydrate report and its subsequent publication in 2015. With no apparent meetings of the group after the SACN Carbohydrate report, one has to assume the publication of the Eatwell Guide by Public Health England in 2016 was independent of group opinions. It is clear from PHE that the guide modelled data from the NDNS to achieve the 30g fibre recommendations of SACN, the 5% sugar calorie recommendation of EFSA, whilst maintaining the Mediterranean-style diet guidelines which are the nutritional blueprint of a healthful diet.

“Nutritional recommendations are influenced by a number of considerations: scientific research, social and economic factors, cultural and environmental issues, and the impact of food technology and food availability.  Pre-occupation with dietary nuances are detrimental to the overall debate, and do nothing to empower the public to feel confident in their dietary choices.

“Reading yet another article in the BJSM I am reminded of a prescient remark from Professor Cecilia Florencio from the University of the Philippines at the 2008 ICDA conference in Japan ‘Everyone has expertise on food related concerns that simply must be out’.”

¹ http://www.zoeharcombe.com/2016/03/eatwell-guide/ back of envelope quote

² Buttriss JL (2016). The Eatwell Guide refreshed. Brit Nutr Bull 41:135. Accessed online 12.06.16 http://onlinelibrary.wiley.com/doi/10.1111/nbu.12211/abstract

Dr Gunter Kuhnle, Associate Professor in Nutrition and Health, University of Reading, said:

“Dietary recommendations need to be clear and understandable. Using vague and poorly defined categories such as ‘real food’ will only increase confusion, without having any benefit.

“Zoe Harcombe’s advice is to ‘eat real food’ – but she fails to explain what this is. ‘Real food’ is a concept that has become increasingly popular in the last couple of years. Despite its popularity there seems to be no consensus on what is included, and what isn’t. Real food is often used synonymously with unprocessed food, yet most traditional staple foods are processed in some form. Red wine, cheese and olive oil, all staples of the Mediterranean diet, are all processed. Are they real food?

“Dr Harcombe is right to demand that dietary recommendations should be based on solid evidence, but this is what already happens in the UK. Public Health England reviews the evidence available. The relevant reports, such as those by the government’s Scientific Advisory Committee on Nutrition, are public and can be read by everyone. It is wrong to claim that there are no data to support current dietary recommendations. Numerous studies have been published over several decades on the impact of dietary guidelines.

“Recently there have been several claims of a link between the introduction of dietary guidelines in the 1970s and 80s, and increasing rates of obesity and diabetes. But the introduction of dietary guidelines is not the only thing that has changed in society in recent decades. People’s lifestyles have changed fundamentally in many other ways and it is simplistic to ignore other factors. It could even potentially be dangerous, as it might make it harder to introduce policies that properly address these critical public health issues.

“As an editorial, this is of course rather a comment on current developments and does not provide evidence on which future policy decisions should be based.”

Prof. Tom Sanders, Professor emeritus of Nutrition and Dietetics, King’s College London, said:

“It is important that good science underpins dietary advice to the public. This editorial is a piece of provocative journalism not backed by science. It attacks the revision of the Eatwell Guide by making a number of flimsy claims and insinuates a malign influence of the food industry. There is not a shred of evidence to support the central claim that current dietary guidelines are responsible for the current obesity epidemic. The obesity and subsequent diabetes epidemic has resulted from changes in human behaviour, notably a more sedentary lifestyle and changes in eating habits, which have nothing to do with the dietary guidelines. For example, increased consumption of food eaten outside the home and larger portion sizes.

“The revised Eatwell Guide puts more emphasis on fresh fruit and vegetables and suggests that meals are planned around starchy foods, selecting wholegrain versions where possible. Foods that make an important contribution to protein are also given a segment as are dairy products or alternatives. The relative proportions are based on modelling from the government funded National Diet and Nutrition Survey. I don’t think you are expected to eat everything on the plate.

“The claim made that the dietary guidelines are not supported by randomised controlled trials (RCT) is plainly wrong.  The Food Standards Agency and later Public Health England commissioned several large RCTs to underpin current dietary guidelines and I was involved in leading several of these. Indeed, we specifically tested the effects of current UK dietary guidelines versus a conventional UK diet and showed that there were favourable effects on risk factors for cardiovascular disease as well as body weight and waist circumference (Reidlinger et al 2015; full reference given below).

“The editorial seems to object to the prominence given to starchy foods, voicing concerns over the carbohydrate content of beans and pulses as well as staple foods such as bread, pasta rice and potatoes. It wrongly suggests that we have only recently adopted a diet where most energy comes from carbohydrate. In fact carbohydrate provided 53% of energy in the Second World War in the UK and subsequently fell to about 45% of energy, where it has remained for the last 50 years.

“It would seem that the author has leanings towards the rather cranky Paleolithic Diet movement, which advocates eating lots of animal protein foods and little carbohydrate, promoting the nostalgic myth of the healthy hunter-gatherer. Hunter-gatherers had short lives and their diets are of little relevance to the generally healthier and longer-lived citizens of the civilized world. Specifically, the editorial implies vegetable sources of protein are inferior by referring to them as incomplete proteins. This view is very outdated. Plant proteins may have different amino acid profiles from animal proteins but, when consumed as mixtures, as in practice (baked beans on toast), their amino acid patterns complement each other to provide a protein intake that is complete and as good as meat.  There are likely to be health benefits from consuming more plant protein than animal protein according to analysis from the large prospective cohort studies. Furthermore, climate change is another reason for encouraging people to eat more plant sources of proteins because farm animal production is a major source of greenhouse gas emissions. My own research has shown that vegetarians, who eat fewer animal protein foods and more starchy foods, are less likely to be obese and suffer from diabetes.

“The editorial also questions sensible advice regarding fluid intake that advocates 6-8 drinks of water, low fat milk and sugar-free drinks including tea and coffee. This guidance is in line with water requirements: you need 1 ml/kcal and as women need 2000 kcal/d and men 2500 kcal/d, that translates into 2 and 2.5 litres/d respectively. About 400-600 ml water come from food, the rest must come from drinking fluid:  6-8 drinks is a reasonable amount that is likely to be helpful in preventing weight gain.

“The headline grabbing strapline “Designed by the food industry for wealth, not health” is totally unjustified. It is only proper that the food industry is consulted in the process as a stakeholder. However, there is no evidence of any product placement in the guide and foods depicted are what we might purchase in a supermarket, not ready meals or branded packaged foods.”

Reidlinger DP, Darzi J, Hall WL, Seed PT, Chowienczyk PJ, Sanders TA. Cardiovascular disease risk REduction Study (CRESSIDA) investigators. How effective are current dietary guidelines for cardiovascular disease prevention in healthy middle-aged and older men and women? A randomized controlled trial. Am J  Clin Nutr. 2015 May;101(5):922-30.

‘Designed by the food industry for wealth, not health: the ‘Eatwell Guide’’ by Zoe Harcombe will be published in the British Journal of Sports Medicine at 23:30 UK time on Monday 13 June 2016, which is also when the embargo will lift. 

Declared interests

Catherine Collins: “No conflicts of interest.”

Dr Gunter Kuhnle: Employment: Associate Professor at the University of Reading.

Grant funding: Investigation of links between polyphenol intake and health – EU, Mars, Horizon.

Appointments: EFSA Working group – risk assessment of soy isoflavones.

Memberships: British Mass Spectrometry Society, British Nutrition Society, Registered Nutritionist (Reg. Nr. 8236); 2011 to 2012 member of ‘Biomarker group’ at ILSI Europe.

Other financial interests: Vineyard owned by family.

Prof. Tom Sanders: Prof Tom Sanders is a Scientific Governor of the charity British Nutrition Foundation, member of the scientific advisory committee of the Natural Hydration Council (which promotes the drinking of water), and honorary Nutritional Director of the charity HEART UK. Prof. Tom Sanders is now emeritus but when he was doing research at King’s College London, the following applied: Tom does not hold any grants or have any consultancies with companies involved in the production or marketing of sugar-sweetened drinks. In reference to previous funding to Tom’s institution: £4.5 million was donated to King’s College London by Tate & Lyle in 2006; this funding finished in 2011. This money was given to the College and was in recognition of the discovery of the artificial sweetener sucralose by Prof. Hough at the Queen Elizabeth College (QEC), which merged with King’s College London. The Tate & Lyle grant paid for the Clinical Research Centre at St Thomas’ that is run by the Guy’s & St Thomas’ Trust, it was not used to fund research on sugar. Tate & Lyle sold their sugar interests to American Sugar so the brand Tate & Lyle still exists but it is no longer linked to the company Tate & Lyle PLC, which gave the money to King’s College London in 2006. Tom also used to work for Ajinomoto on aspartame about 8 years ago.  Tom was a member of the FAO/WHO Joint Expert Committee that recommended that trans fatty acids be removed from the human food chain. Tom has previously acted as a member of the Global Dairy Platform Scientific Advisory Panel and Tom is a member of the Programme Advisory Committee of the Malaysian Palm Oil Board. In the past Tom has acted as a consultant to Archer Daniel Midland Company and received honoraria for meetings sponsored by Unilever PLC. Tom’s research on fats was funded by Public Health England/Food Standards Agency.

None others received.