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Can governments nudge away obesity?
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Can governments nudge away obesity?

I talked to Dr Zoë Harcombe about the Nudge Unit's report into obesity prevention programmes.
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Apology and warning!

For some reason the sound quality was poor, so I’ve produced a transcript too. Scroll through the summary of this podcast and you can choose to read our conversation rather than listen, if you prefer.


Summary

The Nudge Unit has produced a new report, entitled ‘Putting health in the spotlight: quantifying the impact of obesity prevention policies in the UK’.

The report collates government estimates of benefits from four current and scheduled obesity prevention policies and gathers them together in a table. It doesn’t critique them, other than to suggest they were underestimates.

Amazingly, this is a report about quantifying the impact of obesity prevention policies without really quantifying what happens to obesity. There is a simple way to assess whether obesity prevention policies work: assess obesity. This report does not do that. We are more obese, not less obese, despite the fact that ‘obesity prevention policies enjoy considerable public support, and how they positively address existing social and health inequalities’, according to the report. Obesity has increased since the soft drinks levy was introduced, for instance.

Those who already follow me will be unsurprised that the modelling results in such a huge range as to be pointless. This report this is written by people with an appetite for control, levers and revenue. They are less hungry to reduce actual obesity.

Finally, Zoë shares some dietary advice to tackle obesity. Hold on to your plate - it’s quite different to public health advice.

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Transcript

Laura

Hello, and welcome to my podcast Upfront today, I'm very excited to be speaking with Zoë Harcombe. She's a researcher and an author in the field of diet and health. Her PhD was about dietary fat recommendations, and she made some fairly controversial observations, which I think are going to come through in the course of our chat today. So she can tell us about that.

Zoë

I hope so.

Laura

She's the author of some really excellent books, such as The Obesity Epidemic. I thought I'd start off by mentioning that because I found that book fascinating. It exploded ideas that I had about obesity, fat, and cholesterol. Now, if you're listening to this and you follow me, I think you've already worked out by now that not all government advice is evidence-based, such as masks. Well, Zoë's work would blow your mind, because lots of dietary recommendations are also not evidence-based. Zoë, thank you so much for joining me today.

Zoë

Thank you so much for having me. That's a lovely introduction. Thank you.

Laura

Well, you know that I've read all your books, and I've been thoroughly 'Harcombed’. I eat per Zoë Harcombe recommendations now, and it's been really good for my weight and my health and, everything, really. And your books makes so much sense. And it is shocking when you realise that things like eight glasses of water a day, or five portions of fruit and veggie day, or calorie intakes, they're not based on any evidence, are they?

Zoë

No. It would actually be quicker to say, can I find a nutritional message that comes from a government public health message that is evidence-based? I actually can't find one. So the ones that you've mentioned, you might be delighted to know that the alcohol units are also plucked out of the air. There's no evidence for those whatsoever. There's 30 grams of fibre. No evidence of that. Have no more than 30% of your diet in the form of fat. No evidence for that. Have no more than 10% of your diet in the form of saturated fat. No evidence for that one either. The Eat Well plate that was basically designed by the fake food industry is just utterly shocking. But it stood me in good stead, because, of course, when COVID came along, I just thought, well, I don't believe a single public health dietary message that comes from the government. So why would I start believing their public health messages on viruses or masks or anything else? So it's actually served me really well, certainly over the last couple of years. But I just don't trust anything that the public health on the cells. And I know you don't trust anything that the public government says. So I just work it out myself.

Laura

It was the opposite way around me. So, for me, my epiphany that public health advice might not be evidence-based came with COVID and then I've worked backwards. I've done backwards calculations, including coming across you and working out that dietary advice was also not evidence-based. I particularly love what you say about the alcohol units. I mean, it's fascinating that we're told that as a woman, you shouldn't have more than 14 units a week. But it's not based on anything, really, is it?

Zoë

No. I mean, one of the guys who was actually in the committee that came up with those guidelines - it was only a couple of years ago now - he said, oh, no, the numbers were plucked out of the air because we had done all this chatting and we thought we ought to come up with some guidelines. So we just sort of plucked those out of the air, which is exactly how five a day came about. You know, where it's the number of digits on one hand seems achievable. It's sort of a little bit stretched, but it's not too stretched. Seven is probably too much. Three is not ambitious enough. I mean, this is the kind of thinking that goes on in government committees. And then they have five a day coordinators. They actually advertise jobs for people, to go along and say, you're going to now make sure that everyone gets their five a day. And there's no evidence to it whatsoever. And then that's not actually dissimilar to where we're going to hire people to look at track and trace when we know that that's going to make any difference to the spread of COVID or to the health of the nation. We're going to make sure that people have got PPE, and that's really not going to make that much difference either. So, it's just a little bit depressing, actually, that the people who are supposed to be working for us and looking after us and doing the right thing by us are just not. And it's time that everybody, just the few who have, decided to change those.

Laura

Absolutely. So that's a good way to set the scene for what we're going to talk about today. I wanted to discuss a new report from the UK's Nudge Unit, which is called ‘Putting Health in the Spotlight: quantifying the Impact of Obesity Prevention Policies in the UK’. Now, from that title, people will probably get a sense of what they think the report is about and it's going to frustrate those expectations. This report is not about what you think it's about. We'll come to that. But first of all, just a bit of background on the Nudge Unit because some people might not know what it is. Its full name is the Behavioral Insights team. And behavioral insights is about the use of psychology and social science to affect policy making. It’s called the Nudge Unit colloquially because what they do is nudge, they're nudging us into following policies or to be better citizens, model citizens. They have quite grand goals for themselves. The website says is ‘we improve lives and communities by helping all levels of government, the private sector and philanthropies tackle their biggest challenges’. So let's see how that grand goal starts with the report. So I asked you to have a look at the report and you've written one of your Monday Note articles about it. So I'm going to link to that after this podcast. But can you just sum up what this report is about, please?

Zoë

The background that you've given me is actually really helpful because of course, these guys came to the fore during COVID. They were the ones that started off with that absolutely frightening sort of dystopian statement saying, people are just not really scared enough, so we need to scare them because scared people are more compliant. That wasn't exactly that, but it really wasn't that far away from it. And my take on this report, when you very kindly asked me to have a look at it because was that the team had obviously enjoyed coming to the fore during COVID and didn't want to let that centre stage go. So they are now looking to what can they do now that COVID has subsided. Although I noticed that there's talk about bringing back all kinds of nonsense at the moment, so we just have to hope that that goes away. But this report was written in November 22. They're obviously in the place of, what can we do now? We need to keep ourselves rather than in the forefront and lots of money. So they took it upon themselves, they weren't asked by the government to review their obesity policies. They took it upon themselves to review the government obesity policies. But review is what I do in Monday Notes every week. They didn't review the government policy, they examined four particular government policies.

The first one that they looked at in terms of the chronology of coming in was one that came in in April 2018, which was the soft drinks industry levy. Then they looked at restricting placing ‘bad products’, as they call them, at the checkout at the end of the aisle and in store entrances, at the places where we're most likely to see them and then make these impulse purchases. Restrictions on what they call BOGOF, where you buy one and get one free and you notice that they're always on junk food. They're never on steak or fish. And then they were looked at online advertising and what they call junk food, HFSS, high in fat, sugar or salt.

As you and I know, fat is utterly life vital. Salt is utterly life vital. Sugar and carbohydrate and processed food is what they should be going after. But they looked at these four things and then they said, the government has actually produced a number of reports on each of these four things. So we're just going to take all the numbers from the government report and put them together in a table where you could pretty much ask an eleven year old to do that in a math lesson. Then they say there are savings somewhere between £1.75 billion and almost £300 billion. There must be a typo there, you cannot be serious - you're talking about a range as big as one to 300 billion! But no, they were serious, because they didn't critique any of this. They didn't challenge any of this. They didn't step back, they just presented these numbers and then said, okay, it's going to make a difference. Um, that's marvellous… We should nudge people into doing this kind of thing.

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Laura

There are a few things to pick up on already. I mean, the range is just astonishing. And you know what it reminded me of? It reminded me of the modelling during Covid. You know, any number of people could die from this many hundreds of thousands to this many millions. And the range is so large that it's pointless. It's so imprecise that it totally lacks salience, it lacks a point. So that, that was the first thing. But my overall impression when I looked at the report was I would expect from the title ‘Putting Health in the Spotlight’, that the report would put health in the spotlight, not the potential cost savings of interventions. And then it says, quantifying the impact of obesity prevention policies in the UK. So I would expect what they'd be quantifying is the impact on obesity. I thought this report would be about how you improve obesity levels, but it's not really, is it?

Zoë

It's not. And they tried to look at small things, so they tried to sort of estimate the benefits and they tried to put it in a health context, but it just didn't work. So number one, they said, oh, we'll try to work out the health benefit to the individual. They're trying to put a monetary value on the health benefit to the individual. So if the government can take away confectionery at the checkout, then people won't consume that confectionery, which is a giant leap already, because we know that if you're going to get hold of confectionery, you will get hold of confectionery. You don't just have to get it at the checkout. But they want to put a health benefit on a direct result of government policy, and put a financial value on it. I've helped people lose a stone. I've helped people lose ten stone. People don't come back to me and say, how can I put a financial measure on how valuable that was to me. It's just that they feel better, they can play with their grandchildren.

So then they try to say, okay, there's savings to the UK’s NHS. That starts to get a little bit more sensible. Because, of course, if you help somebody to move a stone or ten stones and you move them out of that dangerous territory for Type 2 Diabetes, then you are into savings that could materialise to the NHS. But seriously, it's trying to say, just not having confectionery at the till is going to mean that this person moves away from Type 2 Diabetes and that's going to mean savings for the NHS.

Over the next few years, they try to get into savings to UK social care services. Almost everybody that I've helped to lose weight over the years, I don't think there's any interaction whatsoever with social care services. I might have avoided an interaction with the NHS by not getting Type 2 Diabetes, but social care services a whole different thing.

And then this was the most hilarious one. They said there's going to be increased economic output. How judgmental can you get? So that person who loses a couple of stone is now supposed to be worth more to Starbucks because they can serve that many coffees in a certain period of time. Or if they're working on a car assembly plant, or if they're cutting hair, they can do that better, maybe more haircuts just because they managed to lose a stone. Honestly, I didn't even know where to start. That’s strange.

Laura

I do think that government should obviously do cost benefit analysis for policies, although I think there's a different starting point for a report like this - what the point of the report is, we come to that in a minute - but while they should be doing cost benefit analysis, there is something very cold about it. Just talking about what the perceived economic output improvement will be in a human being if they lose weight, as though we're just units of production. And you're a more efficient unit of production if you're a thinner unit of production and if you're a fatter unit of production. So that was quite strange. But I also questioned the evidence behind some of these policies. You mentioned the end of the aisle purchases. I don't know if this might be a little bit out of your field, but what's the evidence actually, that removing junk food from the end of the aisle impacts obesity?

Zoë

This is an interesting one actually, because I used to work for Mars and I joined Mars working for the electronics division. So I didn't actually join the naughty bit. Not many people know that Mars has an electronics division. Mars wanted to go to burn chocolate in chocolate machines twenty four seven. And because there wasn't a reliable coin, they developed a division to make one. So that was the start of my Mars journey. But I did actually end up in confectionery because if you were going to do well at Mars, you had to go into one of the core businesses which was either confectionery or pet food. So unfortunately, I am able to tell you that seven out of ten people who walk into an area where confectionery is an impulse purchase did not intend to make an impulse purchase. So they go into the petrol station thinking they're just going to buy and pay for their petrol, but they come out with an ice cream or crisps. And they go to the cinema and they intend to just watch the film, but they see the big rack of popcorn and confectionery and it gets them. So yes, if you put something by the till, particularly if you put it at children’s height and it's got the children pester power, you are more likely to buy confectionery. But what this is not allowing for is that to take confectionery away from that particular place doesn't stop people having those other opportunities for the impulse purchase.

Laura

Sorry, that was my point. I don't question it will reduce impulse purchases, but will it affect obesity?

Zoë

No.

Laura

Because will you actually just find the product you want in a different part of the store? Will you make an impulse purchase somewhere else? Is altering obesity simply about removing impulse purchases by a till? That's what I'm questioning. If there's any evidence for that?

Zoë

No, there isn't. The soft drinks industry levy in 2018 is one that we could evaluate. The question that the report didn't ask, and it was a really obvious one to ask, is, okay, we've had one of these full measures, has it made a difference? And it took me about a couple of minutes to find that out. So you go on the government obesity website and you check the obesity figure before that introduction. You see numbers of about 22.7% or something, in 2015 - 2016. Then this soft drinks levy comes in. Obesity is then 24% in 2019 - 2020, and then it's 25% at the most recent view, which is 2020 - 2021, so it's continuing to rise.

The report has all these columns for those four things that I mentioned. The benefits to the individual, the benefits to the NHS social care settings, and then the increased economic output. They could actually quantify, because it's already happened. There a big number of nearly 4 billion that they're trying to say is the benefit that has accrued from this particular measure, net present social value, but it’s not a benefit to the individual in terms of being less obese. A separate issue, was the coffers that had gone into the government from the levy that had been paid on the soft drinks. If the levy had been paid that means the soft drinks were still bought. If they were still bought, presumably they were still consumed. So there's been no benefit to the individual.

Laura

Less sugar has been consumed, presumably.

Zoë

No, because you only pay the drinks levy on the ones that still fail the drinks test. So, yes, if the company had switched out the sugar and the low calorie version, and people have bought the low calorie version, then they wouldn't have had to pay the levy. But the fact that they've paid the levy says to me that people still bought the products that the levy was imposed upon.

The obesity stats say, where's the health benefit?

Laura

So I suppose you could say as the soft drinks levy was brought in in 2018 - I’m playing devil's advocate here - we’ve had the COVID pandemic and the lockdown. And so in the environment, there are lots of factors that would have affected obesity. It's not as though everything stayed the same, and the only thing that changed was the soft drinks levy. But like you say, that the data does tell a story. Obesity has increased since the soft drinks levy was introduced. What it's done is raise revenue. Are these measures really just about raising money for the government while appearing to pull a lever of control? Look, we're doing something, we're doing something about fat children. But actually, it does nothing about fat children, and it just makes money for the government.

Zoë

I think it's actually about the second thing that you said, though. My view is that this is to make the government look like it's doing something, because the government keeps producing reports. And in the latest report, you've got the standard figures that two thirds of adults are above weight category, with BMI of 25 to almost 30. And then, over 1 in three children leaving primary school overweight. This is just a damning indictment of poor children's health.

So I actually think they get so much stick from campaigns, groups like the Children's Sweet Campaign, Sugar, that kind of thing that they want to be seen to be doing something. So, remember, they appointed a panel of the fake food industry to come up with the wrong model healthy eating plate for the UK. So if you go on my site and put in the words Eat Well, I'll call it the Eat Badly plate.

An academic article that I wrote in the British Journal of Sports Medicine on this topic went through it in detail. Public Health England appointed eleven food industry reps. There were a couple of okay people, but the majority were food industry reps and things like the Food and Drink Federation Institute for Grocery Distribution. And they put those guys in charge of designing that plate, which then appears in hospitals. It's embedded into the school curriculum. It's a crime against public health. And they just brazenly do it and get away with it and life just goes on. It just beggars belief if you actually try to look at what these guys are up to. So they don't give a flying XXXX for public health is one conclusion I've come to over 20 years of researching in this world. They might try to make it look like they're doing something, but they absolutely don't care about public health. If they did, they would not put that out as role model healthy eating. They would not let the fake food industry design our role model healthy eating plate.

Laura

Is it possible that they do care about public health? That they're just constantly misguided?

Zoë

No. I have it on good authority that somebody pretty senior in Public Health England knows this, knows where you're coming from, somebody on our side of eat real food and choose that real food for the nutrients it provides. Why can't you put that kind of advice on your plate? Why can you barely see an egg on the plate? Why are they more likely to put Coca Cola on the Eat Badly plate than they are meat? His view is that they have 400,000, I think it is, people working in the fake food industry. So what are we supposed to do? Just close it down? Lose all of those jobs. The big industry view is we can't afford to not be having these industries.That should be the worry for the Department of Employment or the Department for GDP or industry in the UK or whatever, but please just keep it separate from public health.

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Laura

That is an interesting perspective. I don't know if I'm naturally cynical enough to have filtered that myself, but there's a way in which it makes sense. There are many flaws in this report, and we've touched on several of them now. But one thing struck me. The report notes that being overweight and obese puts you at greater risk for COVID. So it makes the point that the government wants people to be more healthy, to be more resistant to disease. Now, that sounds really reasonable, except, of course, we know that one of our biggest non pharmaceutical interventions, one of the most drastic things the government did was to instruct people to stay at home. Of course, the nudge unit, and all the behavioral scientists, were involved in persuading the nation to stay home. So it's a bit like a game of Simon Says. First of all, it's ‘stay at home, get fat’, then it's ‘now lose weight’, albeit with policies that don't necessarily work.

Laura

Let's conclude with genuine advice about how people should tackle being obese. If the soft drinks levy has been imposed and buy one, get one free policies are going to be tackled and impulse purchase is tackled, and we're still obese, why are we still obese? So what's really the cause of the nation's obesity?

Zoë

I'll come to that in just one second. I have to apologise for chuckling when you started talking about COVID and obesity, because it's not a funny topic, but I just had that image of Boris Johnson in January 2021 basically telling the nation, oh, you don't want to be starting a general New Year diet because we all know how tough they are, so just come and get jabbed instead. It's like, where do you even start?

Laura

That was a very odd moment.

Zoë

It was indeed, wasn't it?

Laura

I understood he wanted to push the vaccine roll out, that that was their public health initiative. But to tell people not to try to lose weight… I don't know how effective New Year's resolutions are, but how strange to tell people not to bother to look after their health in general, which would have been a Covid comorbidity, but also just a really positive thing to do for your health anyway. It was discombobulating. It was very weird in a nutshell.

Zoë

What do you do? Ignore all government dietary advice. Ignore that plate particularly. It's absolutely terrible way to eat. Absolutely terrible way to eat. Number one, eat real food. And that plate is is comprised of such a high level of processed food, it's not true. So you don't want to be eating sugary cereals and breads and cakes and biscuits and low fat food. Eat real food, which is basically meat, fish, eggs, dairy, vegetables, fruits. Some legumes are fine, although animal foods are better. Some whole grains are fine, but you want to be eating a baked potato, not bread that's probably got 15 ingredients in it. So number one, eat real food. Number two, choose real food for the nutrients it provides. And that means you should be choosing meat, particularly red meat, fish, particularly oily, dairy, particularly high fat, eggs, particularly the yolks, vegetables, particularly green things. And then the less sugary starchy other options. So particularly if you've got obesity or diabetes, you really want to be moving away from even what we would call real carbs, whether it's brand new potatoes or whatever. Carbs are not your friend if you're trying to lose weight. And then the final one that I would say, which again, is completely counter to government advice - dieticians tell you have breakfast, then have a snack in mid morning, then have lunch, then have a snack, then have dinner, then have something before you go to bed. I'm not sure how you're ever supposed to burn fat when basically you're just sticking petroleum in the engine the whole time. Eat a maximum of three times a day. If you're the kind of person that doesn't like breakfast or lunch, then don't force yourself to have it. If you do, then eat three times a day. But you've got to stop eating between meals. And if you can extend the overnight fast, if you can have your dinner as early as possible and your breakfast as late as possible you give your body a really good window of not having any fuel burning. That's going to increase your likelihood of burning your own body fat. And it's also going to fantastically help you in breeding things like insulin resistance to diabetes and other metabolic conditions.

Laura

Fantastic. Well, thank you so much for the anti-government New Year's health advice! That’s really good. And I can say, having read your books and followed the advice, if you are eating well, if you're really fuelled on protein and good fats, lots of fat actually, then you feel more satiated and you're less likely to stop for those impulse purchases as well. They're a cycle of up and down, and crash and feed, and you can get out of that cycle.

Zoë

Yeah. And it's about not fearing fat. It's not about adding butter to your steak, which I know a lot of people doing, as in the keto world. A piece of salmon is actually going to be more satiating and filling and nutritious and better for you than a piece of cod. Um, and it just happens to be rich and fat. But so many people fear a fat that comes in food, or they choose low fat dairy, and it's just not filling as full fat dairy. So a proper cappuccino will keep you going longer than a semi-skimmed latté.

Laura

I'm going to link to, um, your dietary advice from this podcast and also to the report, because I think your analysis of the report was just fantastic. I'm so grateful that you went through the numbers and the modelling so that I didn't have to. And also, what I'd say to summarise is this report epitomises government policy, which is about taking action without knowing what the right action is. It's a report about quantifying the impact of obesity prevention policies without really quantifying what happens to obesity. It's all about whether these policies might save money and make people more economically productive. But the numbers, the modelling have so many leaps and stretches and such wide margins that you can't even take that seriously, can you? This is a report written by people that love to take action and to control, but without ever really thinking about what makes people obese and how we tackle that. There's nothing really good in there about dietary advice.

Zoë

That's not true.

Laura

It's a very backwards report. Zoë, thank you so much for talking with me today. It was really interesting, as always. I'd love to talk to you again about more of the diet madness that comes up this year, because it doesn't stop, really, does it?

Zoë

It doesn't. So anytime we get more, I'd love to chat again.

Laura

Thank you so much, Zoë.

Zoë

Pleasure. Thank you for having me. Bye.


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About Zoë Harcombe

Dr Zoë Harcombe is a researcher and an author in the field of diet and health. Her PhD was about dietary fat recommendations, and her books include the fantastic The Obesity Epidemic. Follow her on Twitter and check out her website for articles and links to her books. Read her analysis of the Nudge Unit’s obesity report.

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