Wellbeing For Real Life - Food

In this episode of the Wellbeing for Real Life podcast Dr Richard Pile and Dr Aseem Malhotra talk about  food:  our environment, the kind of food we eat whether whole or ultraprocessed, the cost of eating well and of not doing so,  the effect our weight and overall wellbeing, the problems with diets and the influence of the food industry.    They include some of their tips for eating well and getting the most out of the food you eat.

Richard is a GP specialising in Cardiology and Lifestyle Medicine, and author of "Fit For Purpose: your guide to health, wellbeing and living a meaningful life".  Aseem is a Consultant Cardiologist and passionate campaigner to improve the nation's health.  He is also the author of  books The Pioppi Diet and The 21 Day Immunity Plan.   You can find out more about Richard here and Aseem here.

Fit For Purpose is available from Harper Inspire in paperback, e-book and audiobook format, with Richard reading the audio himself.  Find out more here.  This podcast has been produced the brilliant team at  Monkeynut Audiobooks. 

Transcript

Welcome to the Wellbeing For Real Life Podcast. Have you ever wanted to live life better, but found yourself baffled bewildered and bored by complicated, confusing and condescending advice? This podcast is the antidote. I'm Dr. Richard Pile,  GP, lifestyle medicine specialist, and author of Fit For Purpose. Each episode, I'm joined by leading experts, as we explore different areas that affect our everyday lives. This is the Wellbeing For Real Life podcast. 

Richard Pile
Hello and welcome to Wellbeing For Real Life. In this episode of the podcast, we're going to be talking about food and nutrition. I'm Dr. Richard Pile - GP with a special interest in cardiovascular and lifestyle medicine and author of Fit for Purpose. And my guest today is Dr Aseem Malhotra. Aseem,  for listeners who haven't yet enjoyed the podcast, would you be able to tell us a little bit about yourself, please? 

Aseem Malhotra  1:00  
Sure, of course.  I'm a consultant cardiologist by background. I qualified in Edinburgh medical school 2001, practising the NHS for almost two decades. I'm also a visiting professor of evidence based medicine, a big proponent of the lifestyle medicine movement. And my personal mission Richard is to save lives, a million at a time.

Richard Pile  1:19  
Thank Aseem.  Now you and I have known each other for a couple of years or so now. This is a topic that we've discussed repeatedly, and you've written on. I have read the Pioppi diet I've watched the Big Fat Fix. So I just want to start getting straight to it and to ask you the question Aseem -  if it's true that we're all getting fatter,  whose fault is it?

Aseem Malhotra  1:39  
So, first and foremost, the main reason we are getting fatter which has been, you know, something has been increasing the prevalence in Western populations in the UK, certainly since the 1980s,  the evidence that I've analysed and looked at suggests that almost all of this is due to the types of the amounts of foods that we're eating. So this is a diet problem, predominantly, and when you look at the root causes behind that,  the drivers have been really something that's changing the food environment. So, when we talk about the food environment we're talking about the oversupply of cheap sugary ultra processed foods that now dominate, make up the bulk of much of the British diet, half of the calories we're consuming, and to look at the drivers behind what's driven now what's behind that sort of increase in consumption, it's the food industry, predominantly so they are the culprits, in my view, they are the biggest culprits behind this obesity epidemic in terms of the types of foods they produce the way they market them and misleading in health information, and the fact that a lot of these foods are deliberately designed to encourage overconsumption, they interfere with appetite control mechanisms. So for me it's very clear. The biggest culprits behind this has really being the corporate greed, if you like of the food industry.

Richard Pile  2:56  
Okay, so when I was a little bit younger and less experienced as a GP, I once said to one of my patients "unfortunately I'm never going to be able to sell many copies of a diet book, which essentially is a piece of paper on which is written, eat less, move more". Are you suggesting that there's more to it than that because some people might say, well actually, you know, you decide what food you put in your mouth. You decide how physically active you are.  There's the whole issue of fat shaming isn't there related to that, so are you saying there's more nuance to it than that? 

Aseem Malhotra  3:26  
Absolutely.  I think, eat less move more hasn't worked, so theoretically it sounds great, but the question we need to be asking ourselves is what's encouraging this over consumption so you can tell people to eat less Richard, but you can't tell them to stop feeling hungry. So why are we consuming more food? What's suddenly changed in, you know, for millennia, we've been absolutely fine in the last few decades, we've got this massive increase in people being overweight or having excess body fat, and that comes down to something clearly in the environment and it's the types of foods that we're eating that encourage over consumption. In terms of the personal responsibility argument I think that has a role to play, of course, we all have to excercise personal responsibilty to some degree, but to really properly excise this responsibility you need to have knowledge, the correct information,  you need to have choice, you need to have access to healthy foods, and it needs to be affordable. And for many people that doesn't exist, and for most people, they're not getting all of those four. So we need to address that. And then once we do address that we realise actually this is not predominantly an issue of personal responsibility, this is an issue of the fact that ultra processed food or junk food has become unavoidable. Wherever you go, not just on the high street, whether it's in the petrol station, even our hospitals which for me when I started my campaigning, you know, I started with focusing on hospital food. Even our hospitals have become a branding opportunity for the junk food industry, you know 75% of the food purchased in hospitals, places where people go to get better, is junk food, both amongst staff and visitors and patients. So there's clearly something wrong, it's gone to such a degree these sorts of foods become available to anyone anywhere at any time, even someone who's bed bound, and also who can't even go to the shop where they were selling the sort of food.  There are contracts with hospitals where sugary drinks crisps and confectionery has to be brought to their bedside. This is just extraordinary. And what it does is it legitimises the acceptability of consumption of these foods, it makes people think subconsciously or consciously that it's not that important, that it's not having a big effect on their health.   "Why is the place where I've come to get better and to heal, why are they serving these foods?  It clearly isn't a problem". So, you've got to throw all of these things in to try and understand what's going on when it comes to the obesity epidemic.

Richard Pile  5:43  
And you and I are both fully in agreement on that I think environments, our default setting, is so important, and I'm aware, you know, I practice in an area which is probably quite affluent, generally speaking, but, you know, within that area there are pockets of deprivation where life is very different for some of my patients compared to others, and making those choices, particularly where it's what's right in front of them is really difficult. If we move beyond the environmental settings I know that you've campaigned on a national scale for better nutrition, and I'm fully supported of that, absolutely. If we move beyond that in terms of individuals and their knowledge and their choices (you talked about knowledge being important), if you're talking to someone, a patient example, it can be really complicated, or at least it can feel complicated.  You and I both on social media.  We see all these different diets that are proposed: we've got the vegans going toe to toe with the carnivore lot, and people going into really quite high levels of detail about what to me sometimes like very small bits of a diet.  How do you approach it if a patient is struggling, how do you break it down for them and make it digestible to them?

Unknown Speaker  6:54  
I keep very simple.  I explained to them why first of all it's not their fault. I think it's really important for us as doctors, clinicians to empathise with our patients, you know.  There are two keys to successful patient outcome Richard.  One is your clinical knowledge and your clinical expertise and the other one, other side which often is unfortunately selected is patient empathy. So empathise with the patient.  Tell them it's not their fault because it isn't actually it's not that we're lying to them, it most cases it's not their fault.  Circumstances and misinformation has brought them, led them into the consultation room in the first place in many cases, and then I explain to them.  I just break it down saying what's actually going on here is this is not you being greedy or so forth something is driving your consumption. Often it's, you know there are mental issues related but it's often the environment,  it's this misunderstanding, not realising that actually, the stuff that the 200 calorie shake or something whatever, ultra processed food you're putting in your mouth isn't just 200 calories, it's doing all these things to your body. So it's going to have an adverse effect on your health but also what it's doing is increasing your appetite and I tell them if they break the addiction from ultra processed foods and sugar to baseline things that they can do and explain how to do it, then they will actually find they're not fighting their hunger.  They will feel fuller for longer and it will make it easier for them.  It's not necessarily going to be the silver bullet for everybody, but it makes it much easier for them to lose weight and reduce the consumption of all these unnecessary calories, contribute to weight gain and making them unwell.

Richard Pile  8:27  
When you talk about  ultra-process ed  foor Aseem , I find that essentially a complex concept to discuss. I jokingly say to patients that  if ingredients on a food packet read like a chemistry test, then you know it's probably a highly processed food, but how do you how do you define that if someone says, Dr Malhotra, you told me not to eat ultra processed food. What do you mean by that?

Aseem Malhotra  8:49  
Yeah, so for the purposes of the listeners first and foremost this comes from an international classification it's been developed in Brazil called the Nova.  It's not an abbreviation so it's called Nova classification and categorise various different food groups and ultra processed foods essentially are any packaged food that has five or more ingredients, usually with unhealthy oils, sugar and starch and comes with additives and preservatives so I break it onto my patients and say "so listen, if it comes out of a packet, and you can count five or more ingredients of ultra processed then best avoided."  Now that is now 50% of the calories being consumed in the British diet.  It's pretty extraordinary right? About 70% of our sugar consumption actually comes from these hidden sugars and these sorts of foods. So I say it's about eating real food or minimally processed food, avoiding the ultraprocessed stuff and I just explain to them this is what you do.  People can count five ingredients, most people can do that quite easily. Brown bread in the supermarket is ultra processed food. I explain to patients this is toxic to your body, you should not be eating this stuff.  If you look at the ingredients, people listening to this go into supermarkets and go and pick up a, you know, I'm not gonna name a particular brand but pick up a loaf of brown bread and count how many ingredients on the back of it. You know there's about 12 to 15 sometimes 20 ingredients. It's extraordinary. It's got additives and preservatives, and there's science behind this as well. It's not just something that I'm making up here.  There are scores of studies now showing the consumption of these foods are linked to many diseases, but also this data shows how it has an adverse effect on the bacteria in the gut so it kind of affects adversely the good bacteria in the gut and promotes bad bacteria, which in itself drives, inflammation in the body and this is also is another driver of these diseases. So I think that that's what we should be focusing on.

People say well actually ultra processed food is really cheap. I only have to pay, you know, £1 or £1.99 for my ready meal.  How do you approach that in terms of the cost of eating well?

That's a very difficult one to approach, and it's an important point you raise Richard.  So, me personally, I'm campaigning and you know I was somebody that was very instrumental in bringing about sugary drinks tax and all that kinds of stuff.  So policy changes need to happen where we make healthy foods more affordable and make the sorts of junk food more expensive and that on a population level will actually shift things towards people eating healthier, but for individuals it's a bit more challenging. They will know themselves, they will have to figure out how much they're able to spend, but even if they can't reach that utopia of completely cutting off the processed food, they can certainly shift towards healthy foods. So for example, you know, an apple is cheaper than a chocolate bar. So I just tell them just to have a think about it.  Whole fruit & vegetables, generally actually are not that expensive.  They can be cheaper, but they're not that expensive but you're right, of course you can get packets of sweets or biscuits in big bags that have about 2000 calories in them, and cost, no more than a couple of quid. I think it's also trying to help them to understand that, that extra little bit that they may have to pay is going to pay them health dividends in the short and long term as well.  

Richard Pile  12:02  
It's something that they can take into account, isn't it?  There are other benefits to doing that. I think the point you made just then is really important in that, just like we've talked pragmatically about sleep and about movement in previous episodes, we need to recognise that we don't need to achieve perfection to do we?  If someone's currently eating a rubbish diet seven days a week. If they eat better, two days a week or three or four days a week, clearly that's an improvement on the current situation. And it may be that, economically they could have some days where they go for the slightly more costly food and other days just accept that we don't live in a perfect world. I for one, sometimes I have been known as any of my colleagues at surgery will tell you to pop into town and purchase a beverage from an unnamed coffee shop, which is probably got more sugar in it and it's good for me but in reality, that's just part of life, you know, Moderation I think is what I preach. 

Aseem Malhotra  13:00  
The problem is when people don't understand moderation a lot of the time.  But I think that what I do agree with, Richard is this:  I encourage people to try and do this for a month because you can see health benefits from dietary changes very quickly. But also, it's not necessarily a long term thing that you have to live like this forever.  If you don't enjoy the diet that you're going to be on this is also no point.  Quality of life is also affected by food.  I recommend the 80/20 rule.  Instead of having those treats every day, reserve them for the weekend. That sometimes is enough for people to kind of feel like they can manage, you know that they're not completely restricting themselves from having a pizza on the weekend or fish and chips or whatever it is that they enjoy eating because you know these are enjoyable foods, the problem is we're just overdosing on them.

Richard Pile  13:44  
"I think one of the problems to me is the use of the word "diet" really, in that people will say "I'm on a diet" (and you and I might use the word diet)  possibly not in quite the same sense as medical professionals.  I think for many of us, it implies self denial, sacrifice, maybe eating foods that aren't all that enjoyable, kind of short term maybe to kind of get some accelerated weight loss. So, one of the things I talk to patients about is to try not to think of it in those terms, more of a way of life and something which is sustainable and pleasurable.  Finding food that you like.  It may be that two or three meals a week, you look at a "healthier version" in quotes, of what you've been eating that involves a bit more in the way of vegetables, a bit less in the way of processed food, and you gradually build up your repertoire of better versions of those kinds of things.

Aseem Malhotra  14:36  
Yes, for sure. I think that's key.  I also motivate them saying this is really enjoyable.  Certainly with the evolution of all the science around nutrition and health, we know now that eating fat, providing you cut out the processed food and you minimise the low quality carbohydrates, is as likely to make you fat as eating green vegetables is to turn you green.  My cardiac patients are really happy when they can enjoy steak a couple or three times a week, it's not going to give them heart disease.  It's the ultra processed food that's a major issue, and the starchy foods and low quality carbohydrates, the carbohydrates like the breads and the pastas and the rice that lack fibre.  It obviously depends where you're starting from.  In our country now unfortunately more than 60% of the adult population are overweight or obese and I actually talk about being over fat in terms of excess body fat, probably affects around 80% of people because body mass index, a measurement tool we use to assess someone's having a healthy weight, is outdated. It actually fails to pick up to 40% of people who will have excess body fat who have been told they've got a normal BMI, body mass index, which is just a marker of your weight in kilogrammes divided by your height in metres squared.. It doesn't take into consideration your ethnicity or age or muscle mass and all that kind of thing including  body fat percentage. So, one of the other things I also tell people is, even if you don't lose weight, if you do certain dietary changes and adopt a certain type of dietary pattern which has mixture of vegetables and some olive oil and nuts and oily face that kind of thing and you minimise the junk food - that in itself, independent of weight loss, will have a beneficial effect on your health in terms of reducing the risk of heart disease. And so that's also a little motivational factor for people struggle for example to lose massive amounts of weight but they've changed their diet.  They're already in a much better place and they're healthier, even if they haven't lost loads of weight. 

Richard Pile  16:25  
That's really helpful because sometimes patients don't lose that weight, either because it's hard for them to make changes or perhaps because you know that they've lost some fat and they've put on some muscle and they stand on the scales, and they struggle a bit with that. I think that's a really good point to make and another thing I tend to say to patients as well.  I know that you've often been quoted as saying you can't outrun a bad diet.  A lot of my patients say to me "right, and I know I need to lose a couple of stone so what I'm gonna do is, I'm gonna do a load more exercise". How do you address that without discouraging them?

Aseem Malhotra  16:56  
I explain to them keep moving, but it's all about what you put in the top end. You can't outrun a bad diet.  I explain to them that you know that 75% of all the calories that your body burns happens from doing nothing at all, just for you to breathe, your heart to function. So I explain all that to them and then they kind of get it a little bit. I'm not telling them not to be active but one really good quotes that kind of emphasises this point came from a former surgeon called Lord Ian McCall (he was a shadow health minister when Margaret Thatcher was was Prime Minister) you know he's very much interested in obesity and he gave a quote for an article I wrote where he said  "an obese person doesn't need to do increase their level of activity one iota in order to lose weight, they just need to eat less".  It's about healthy weight loss. That's the crucial thing but I just make that point to them.  For many people and certainly for myself I know this, exercise actually is sometimes a way of putting on weight, not just about muscle but it increases appetite for a lot of people. So if you're in a situation where you're doing more exercise and you've been really hungry and then you're over consuming the wrong types of foods, it can actually send you the other way from a weight perspective, and we forget to mention all of this stuff. Plus, all the data shows us when it comes to weight loss when you compare randomised trials of people that just did a dietary intervention versus people who did dietary invention and exercise, there was no difference in weight. In fact, in fact, in many cases the dietary intervention alone, cause more weight loss than doing the activity, probably because the activity might over time increase stress hormones, probably because it's increasing appetite when all these other things are thrown in. So keep the activity moderate,  keep it simple. I mean, people who are very overweight,  over exercising can be damaging it, increasing the risk of injuries and all that kind of thing. So they should just be keeping it very moderate doing the dietary changes losing amount of body fat in a healthy way, and then they actually find they can do more activity for their enjoyment and their health.

Richard Pile  18:57  
That's really encouraging because then the patients who say to me "I know I should be more active, but I've got bad arthritis in my knees,"  I can say to them "Well the good news is that actually to lose weight, you don't need to be running up and down the block".  And another point that I also make to patients as well is that, in terms of making a sustainable long term approach to it I tend to say to them look, let's talk about your lifestyle and the way that you want to live, and the reasons that you want to live like that because actually, if you've made those healthy changes whether it's better sleep better nutrition, better movement, weight loss should be perhaps ideally a side effect, a beneficial consequence of that, for most people, not the primary goal in terms of measuring

Aseem Malhotra  19:40  
Absolutely, health first. Weight loss as a side effect.  That's what I tell them.  I think we're being more honest and more scientific, in that approach actually because you can lose weight and lots of ways you can starve yourself.  That's not going to be healthy. So how about let's focus on the healthy stuff, and the side effect will be, probably in most cases, weight loss.

Richard Pile  20:00  
So since we like to keep it practical, on this podcast, we've covered a lot there in a short space of time, but let's narrow it down and focus it as we come towards the end.  Shall we start with a couple of top tips each as to how you would recommend people approach food.

Aseem Malhotra  20:13  
Yeah, I would say, depending where you're starting from, I would say the first thing to do is break the addiction cycle.  You've got to know these foods are actually addictive and you need to go cold turkey to get the best effect if you can. So I'd say cut  the ultraprocessed foodme, maybe to start with that.  It's a simple measure, and if you can then after that or at the same time, the low quality carbohydrates to break the addiction to the very high sort of glucose, high starchy foods if you like that's what I would say

Richard Pile  20:39  
That's a good start.  I also talk to people about setting up their environment for success.  If you want to make these changes, clearly what's in your cupboards and what you keep on your desk and what you take to work with you, all of those things influence what you end up eating.  Well, it actually determines what you end up eating doesn't it?  So I talk to people about getting rid of some of the highly processed stuff in their cupboards, thinking about making their pack lunches, and just the kind of snacks that they like to have within arm's reach on the desk and putting the stuff that's less healthy at the back of the cupboard so when they choose mindfully to have a treat, that's absolutely fine, because life's about moderation, but they're making a deliberate decision to do that as opposed to kind of reaching out and grabbing a handful of whatever's on their desk.

Aseem Malhotra  21:23  
Yeah absolutely.  That's really important Richard actually. If people can improve their environment themselves it makes it much easier and less likely for them to choose to pick up junk foods.

Richard Pile  21:32  
What about the timing of of eating Aseem? There's quite a lot of information out there.  There are various terms but the one I've heard used commonly is "time restricted eating." Do you have a view on that?

Aseem Malhotra  21:43  
I think for some people, it helps, it's fine, I would just say you're body tells you to eat when you're hungry and eat till you're full. And if you're eating nutritious, healthy foods, you'd be fine.  Some people can obviously benefit from fasting or time restricted eating. Yes, they do and if they enjoy it that's great. I think the downside for some people, if you're stressed, it can actually make your stress levels worse because your cortisol levels get raised when you're fasting and that can have a very detrimental effect.  So just see where you're at, and if it's something you're doing, you enjoy and you feel fine then great, carry on. If you're not able to do it, then I wouldn't worry.  I don't personally think that there is any very strong data at the moment that it has a hugely additional beneficial effect certainly not for weight loss, it doesn't do that. It may have some effect, and the science is evolving on this.  Starving the body from food for a certain amount of time could have regenerative effects on the body but most of that data has come from animal studies but it's an evolving space in terms of humans.

Richard Pile  22:40  
Thank you. I think that leads on to my last tip.  You were talking about people taking an approach that's right for them.  My last tip is about really being kind to yourself.  Just like we talked about the reasons why we might have disordered sleep in a previous episode, there are lots of reasons why people might have disordered eating. It could just be that we live in a toxic environment with all the challenges that you've already outlined, but of course a lot of it can come from adverse life experiences,  particularly adverse childhood experiences. And again, there may be issues that perhaps people need to talk to a friend or counsellor or their doctor about, in order to actually address some of those deep seated underlying issues before they fret too much about calories or the type of diet that they're consuming, and just giving themselves a break and recognising that some days they will have a good day. Other days might not be such a good day, but at least they've still had the good day. And I think if they are kind to themselves and learn from mistakes, from plans they made it didn't come to fruition, then  instead of being defeated by that, instead of giving up on it, they can use that knowledge to build on it,  to make it more likely that they'll succeed in finding a way that works for them next time. 

Aseem Malhotra  23:50  
Yeah sure, and of course some of these people are going to need extra help Richard as well, so we need to remember that all these things are linked and there may be a mental health issue and maybe excessive stress. They may need extra guidance and support from for example, a health coach and nutritional therapists, a dietitian, for example, so I think we need to realise that the multidisciplinary team is there, and for some patients actually just beyond the general advice they may need extra support and hopefully we can guide them and help them get that.

Richard Pile  24:17  
I think that is a really good note on which to end. Thank you once again for your time today Aseem.  I've really enjoyed our conversation I hope our listeners have too, and I look forward to speaking to you soon. 

Aseem Malhotra  24:27  
Thank you Richard. It's been my pleasure. 

Richard Pile  24:30  
You've been listening to Wellbeing For Real Life with me, Dr Richard Pile. If you've enjoyed this episode, please give it a nice review and tell other people about it. If you'd like to learn more, my book Fit For Purpose is out now, published by Harper inspire and available in paperback ebook and audiobook. You can also follow me on Twitter, YouTube, and my website https://wellbeingforreal.life. This podcast was recorded at Monkeynut Audiobooks. Until next time, take care of yourself.