Dr Aseem Malhotra: Lessons in public health advocacy
Dr Aseem Malhotra is a renowned cardiologist, working in the NHS and leading the campaign against excess sugar consumption in the UK. He speaks regularly at national and international events on matters of heart disease, obesity and diabetes. As a strong believer in evidence-based medicine, he urges the healthcare community to be more open and knowledgeable about scientific data. This talk was given at the Public Health Collaboration conference 2018 at the Royal College of General Practitioners in London.
Half of what you learn in medical school will be shown to be either dead wrong or out of date within 5 years of your graduation; the trouble in nobody can tell you which half. The most important thing to learn is how to learn on your own – Dr David Sackett
Dr Malhotra begins by outlining the concept of ‘evidence-based medicine’ which seeks to utilise individual clinical expertise, the best available clinical evidence and consideration of patient values and expectations to deliver improved patient outcomes. This practice may be instrumental in tackling the current public health crisis, in which 2/3 adults and 1/3 children are overweight or obese, with obesity and type 2 diabetes costing the NHS over £5 billion and over £20 billion per year respectively. These costs are only set to increase further if adequate action is not taken.
So what is to blame for the obesity and diabetes epidemics? Dr Malhotra opines that the primary driver is the over-availability of sugary and processed snack foods. Most people will agree that such foods are unhealthy, yet they are found pretty much everywhere, sold as convenience foods. To illustrate just how much of a problem this can be, Dr Malhotra tells us a story about a patient of his being served a burger and chips in hospital the morning after having an emergency heart procedure. He also notes that many of the staff are suffering from health issues due to the unhealthy food served in the canteen. Luckily, campaigning can make a difference. Dr Malhotra himself has written pieces, given talks and even collaborated with Jamie Oliver to raise awareness of these issues and influence positive change.
So why is diet Dr Malhotra’s major focus for improving public health? It has been found that poor diet accounts for more global ill-health than smoking, alcohol and physical inactivity combined. To put things into perspective, half of UK family food purchases are ultra-processed foods, and these are coming predominantly from sugary products, drinks and starches. In order to improve public health, Dr Malhotra explains that real food needs to be made available and affordable for everyone via policy-based interventions.
The sugar debate is not actually a new one – the likes of Ancel Keys and John Yudkin argued over the matter from the 1950s and 60s. However, Yudkin’s warnings about sugar had little impact back then and the blame for poor health was shifted to fat (saturated fat in particular). More recently, other healthcare professionals and researchers, including Professor Robert Lustig, have come to the fore to rekindle discussion on sugar. Currently, Americans are consuming far more sugar than is recommended by the American Heart Association (9 teaspoons per day for men). Through his own research, Dr Malhotra found that European countries, including the UK, have been recommending 22 teaspoons of sugar per day as part of a balanced diet. He opines that the food industry may have hijacked this recommendation to remove a distinction between natural sugars in whole foods and added sugars in processed foods.
According to Dr Malhotra, another paradigm that has played into the hands of the food industry is the idea that physical inactivity and overeating are responsible for poor health, thus placing the blame on the public. Dr Malhotra explains that this shifting of blame, along with smearing of critics and cherry-picking of data, is a tactic from ‘the corporate playbook of big food’ to prevent public health regulations on sugar, and that these tactics are analogous to the ones used in the past by the tobacco industry. In addition, the individuals involved in writing nutritional guidelines often have conflicts of interest including financial ties to processed food companies.
Taking a more balanced, unbiased look at the evidence allows better identification of the factors underlying poor health. Dr Malhotra explains that clogged arteries are caused not by dietary saturated fat, but by insulin resistance due to, amongst other factors, a diet high in processed carbohydrates. Focusing on the true causes of a problem allows appropriate action to be taken to prevent it. Dr Malhotra therefore suggests that a Mediterranean diet high in healthy fats and low in processed carbohydrate can act to treat clogged arteries.
The food industry is not the only one exerting its influence on the guidelines and literature. Dr Malhotra goes on to draw links between the actions of the food and pharmaceutical industries. He reiterates points he made last year, stating the UK has a problem with overmedication, particularly with statins, and that much of the data driving clinical decisions has been corrupted by commercial influence. In addition, most of the ten largest pharmaceutical companies were found guilty of corporate crime. These issues, Dr Malhotra says, need to and are beginning to be tackled head-on.
Dr Malhotra rounds off the talk by saying that respecting evidence, exposing injustice and encouraging transparency will be key to removing commercial interest from clinical literature and public health decisions. He also leaves us with Simon Chapman’s top tips for advocating public health. Doubtless, the efforts of Dr Malhotra and other such public health campaigners have had and will continue to have huge impacts on mainstream thinking around nutrition, medication and health.