Challenges and opportunities for better nutrition science—an essay by Tim Spector and Christopher GardnerBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2470 (Published 26 June 2020) Cite this as: BMJ 2020;369:m2470
All rapid responses
Re: Challenges and opportunities for better nutrition science—an essay by Tim Spector and Christopher Gardner
It is time to act against drug-foods, for the health of the population and the planet.
The BMJ ‘Food for thought’ collection, including Spector and Gardner’s more recent paper, have tended to focus on individual actions and the doctor-patient dyad. We however suggest that a root cause approach which not only asks ‘Why is my patient obese?’ but also ‘What factors have resulted in the increase in obesity?’ would lead us to consider the role of what Mintz termed ‘drug-foods . Once we as doctors start to think of these substances in the way we think of drugs, our perspective changes. But what do we mean by ‘drug-foods’? Sugar, cocoa and caffeine were first termed drug-foods but the definition we use here also includes products containing non-sugar sweeteners, and those, such as savoury snacks, which are specifically formulated to be ‘moreish’, to stimulate pleasure responses above and beyond the natural pleasure derived from eating. Indeed, recent RCT evidence shows that ultra-processed foods (which themselves contain drug-foods) are associated with weight gain when directly compared with non-processed food.
The health consequences of over-consumption of these drug-foods are now, in the middle of the covid-19 pandemic, even more obvious to us all, and they come at a huge financial and social cost in the burden of obesity, pre-natal and infant malnutrition, alcohol harm, and diet-related dental and mental health care.
As well as the health effects of drug-foods, it is less well-recognised that their production uses a substantial proportion of our increasingly stretched natural resources. PepsiCo, for example, sent 6% of the 2018 UK potato crop to their Walkers crisp factory in Leicester.
Coca Cola’s water consumption in 2012 was enough to meet the annual needs of over two billion people,  a figure greater than the UN Food and Agriculture Organization (FAO) estimate that, by 2025, 1.8 billion people will be living in regions with absolute water scarcity.
It is widely accepted that human health and planetary health are intrinsically interlinked: both are threatened by climate change, resource depletion and population pressures. The Rockefeller-Lancet Commission on Planetary Health recognised the role of powerful vested interests as a significant barrier to action and the former UK Chief Medical Officer in her final Annual Report [Ch 8, p16] also reminded us of the power of vested interests: in a section titled The lessons of history, she says: Early on it was recognised that the key driver of smoking was the existence of an industry with highly sophisticated strategies to maximise reach and sales.
In the UK, both drug-foods and the producers and promoters of them can be identified through an aspect of the UK fiscal system, namely Value Added Tax (VAT). The use of the VAT system precisely and systematically identifies both the drug-food products and their manufacturers at the point of sale. We therefore suggest that for food and drink products upon which UK VAT is levied, advertising and product placement should be prohibited and, as with cigarette products, strict controls placed on branding and packaging design. It is of note that there are similar point of sale taxes in other jurisdictions, e.g. the Good and Services Tax (GST) in Australia.
We therefore suggest the following strategies: (i) that corporations making and promoting any food and drink products upon which VAT (and similar taxes in other jurisdictions) is levied are prohibited forthwith from sponsorship and/or partnership (including commercial partnerships such as vending machines) with national and local government bodies, nurseries, schools, colleges, universities, research organisations and health systems; (ii) these corporations are charged a levy to offset societal costs and the fiscal costs borne by the health system; (iii). limits are placed on their use of land, soil, water and energy, as well as consideration given to charging a proportion of agricultural land subsidies received directly or indirectly; (iv) the monies collected be used to support agricultural products and practices supportive of both human and planetary health.
The UK Government’s new obesity strategy appears to depend largely on individual behavior change and nudge strategy, rather than being an effective population level strategy. Just as the tobacco companies have in the past endeavoured to subvert public health messages, so today we must take radical action to curb corporations producing drug-foods. We must not, however, underestimate corporate power lobbying governments. Indeed, the individual power of one company, Coca Cola, has been recognised in two recent BMJ papers. Seeking any means by which any of these corporations would voluntarily curb their commercial activities runs counter to their raison d’être and is therefore futile. As John Naughton eloquently describes, we can regard corporations as artificial superintelligences, thus amoral rather than immoral entities, blindly seeking to extend their power and reach, indifferent to human and planetary interests.
Our urgent challenge is to speak truth to this truly sociopathic power and act both individually and collectively against it. And if doctors won’t act, then who will?
1. Mintz, Sidney W Sweetness and Power: The place of sugar in modern history p99-100. Penguin 1986. ISBN 978-0140092332
2. Elmore, Bartow J Elmore (2015) Citizen Coke: The making of Coca Cola Capitalism. W W Norton & Company. Chapter 1 Tap Water: Packaging public water for private profit, page 18, footnote 1. ISBN 978-0-393-24112-9
Competing interests: No competing interests
We welcome Spector and Gardner’s1 timely essay on the opportunities for better nutritional science. As jobbing NHS psychiatrists, we know too well that people with severe mental illness such as psychosis disproportionately suffer from obesity, metabolic syndrome and type 2 diabetes, often secondary to the adverse effects of antipsychotic medication2. Some would argue that patients detained under the Mental Health Act may be at further risk of developing metabolic problems due to meals lacking nutrition provided in hospital settings. Despite the introduction of NHS England physical health CQUINs in mental health settings, weight gain is often monitored poorly and any interventions offered are ineffective. The recommended interventions in the NICE guidelines on obesity3 include calorie restriction and low-fat diets which we argue are outdated methods of weight management. Weight gain is unfortunately seen as an inevitable consequence of taking psychotropic medication.
Furthermore it is notable that severe mental disorders such as psychosis disproportionately affect lower socioeconomic groups, as does obesity. Structural inequalities exist such that makes it very difficult for people on a limited income to buy fresh produce and to avoid buying ultra-processed food. Supermarkets are structured in a way that maximises sales of its least healthy foods and ultra-processed food products are often marketed as healthy with attractive branding. The harsh reality is that the food industry controls much of what we eat. It follows then that the term “lifestyle medicine” may be a misleading term as some people’s choices are very limited.
The lack of consensus of what constitutes a healthy diet is deeply concerning. Nutritional experts often disagree with one other and there is a plethora of contradictory diets. As a result mental health professionals do not feel confident about giving nutritional advice to their patients and the public are unsurprisingly confused about what a healthy diet is.
What is emerging and gaining traction is a growing body of evidence of weight management on low carbohydrate diets. We are encouraged by the recent work of Unwin and Unwin4 in reversing type 2 diabetes through the low carbohydrate diet in their cohort of community patients in primary care. We also welcome the recent reassessment of recommendations around foods rich in saturated fat, that the available evidence does not recommend limiting these foods5.
We can see that the tide is turning but it remains a travesty that better nutritional research does not exist, particularly for patients with severe mental illness. We owe it to our patients to do better.
Reem Abed and Gurpreet Kaler
Spector TD, Gardner CJ. Challenges and opportunities for better nutrition science BMJ 2020; 369:m2470. doi: https://doi.org/10.1136/bmj.m2470
De Hert M, Correll C, Bobes J et al. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care World Psychiatry 2011; 10(1): 52–77. doi: https://dx.doi.org/10.1002%2Fj.2051-5545.2011.tb00014.x
NICE 2014. Obesity: Identification, Assessment and Management [Online]. Available at: https://www.nice.org.uk/guidance/cg189/resources/obesity-identification-... [Accessed: 1 July 2020].
Unwin D, Unwin J. Low carbohydrate diet to achieve weight loss and improve HbA1c in type 2 diabetes and pre-diabetes: experience from one general practice Practical Diabetes 2014; 31(2): 76-79. doi: https://doi.org/10.1002/pdi.1835
Astrup A, Magkos F, Bier DM et al. Saturated fats and health: a reassessment and proposal for food-based recommendations: JACC state-of-the-art review JACC 2020; doi: https://doi.org/10.1016/j.jacc.2020.05.077
Authors’ declaration of interest: none
Competing interests: No competing interests