Book Review: The Pioppi Diet
Post date: 11-Mar-2018 09:46:52
If you have an interest in health and exercise and have spent any time on twitter in recent years you will have seen the conversations surrounding Tim Noakes and Aseem Malhotra on issues such as Carbs v Calories, Exercise v Diet and Truth v Industry-led Propaganda. It was therefore with great interest that I recently had the chance to see Dr Malhotra speak at the Welsh Exercise Medicine Symposium 2018 and was able to see what he would choose to talk about and how he was going to support his arguments.
Full disclosure, my own starting point in this debate is that I think we should be aiming to reduce sugar intake as much as possible and limit excess calorie intake but not necessarily reduce carbs as much as many of the #LCHF disciples think is required. So it was that I came away feeling surprised by how much of his keynote was built on solid foundations such as Kelly Brownell’s work on corporate influence and how little of it was in support of aggressive carb reduction. I was slightly confused after seeing much of the online debate and felt that he wasn’t quite as #LCHF as his followers would have us all believe. I was left thinking I’d better read his infamous Pioppi Diet Plan and find out what all the fuss is about.
Prior to reading the book I knew about Malhotra’s LCHF tendencies, I knew that it had been placed in the five worst celebrity diets by the British Dietetic Association (an issue that made Malhotra very angry at the symposium and which he dismissed with cries of industry bias) and I knew that it was called “The Pioppi Diet: A 21 day lifestyle plan” a title that manages to contradict itself by suggesting that changes made in 21 days are thus a lifestyle change. This last issue had grated with me since I first saw Malhotra plugging the book but after seeing him speak I thought I’d give him the benefit of the doubt as it could be a cheap shot by the publishers and not necessarily a main theme of the book.
The premise of the book is that the authors visited Pioppi, a small fishing village in Italy (population 197) where Ancel Keys once lived and which in turn became the main inspiration and study site for The Mediterranean Diet work that Keys became famous for. Malhotra and his co-author Donal O’Neill visit Pioppi over an undisclosed period and in this book use their experience of life in the hamlet to make links to the science behind healthy lifestyle choices. This link with Pioppi is however, where much of the confusion is to be found in the book.
Relevance to Pioppi
At times, they draw links between the lifestyle behaviours of the villagers and subsequent mortality and morbidity rates using this evidence to underpin the diet that takes its very name from the village. Villagers have consumed low levels of processed foods, eat regular meals, snack less, don’t eat as much pasta as we think the Italians eat and don’t do exercise, “No Gym, No Supermarket, No Problem”.
The problem with this essential link in the narrative is that the author’s pick and choose when to emphasise its existence. Why should we limit the amount of processed food we eat...look at Pioppi man, he doesn’t eat fast food. Garlic...a staple of the mediterranean diet and great for cardiovascular health. Sugar?...In Pioppi, it’s only considered a rare treat and desserts are only eaten on Sundays. Exercise...the people of Pioppi would scoff at the thought of doing exercise. All good so far, but hey what about doing some pilates, how about Tabata? Turmeric anyone?.
I can accept that Italians don’t eat pasta quite as much as many of us might think they do, but they do eat it and it would be in the diet of most Pioppian’s. I can’t say the same for many of the recipes that are in the meal plan which include Jerk Chicken Cauliflower Pizza, Chicken Schnitzel with Sauerkraut, Spicy Salmon Curry, Korean stir fried pork belly and Karahi Lamb; I’d love to know how many locals eat these meals regularly yet our author’s fail to tell us any stories about how they know that they do.
Chapter 16 is simply titled, “Aseem and Donal’s Top Ten Foods” and while no introduction or context is given to the chapter, or much reference to Pioppi, there’s a list of foods that are recommended by the authors. Most of it is pretty standard healthy eating advice but with no mention of the obvious anomaly there is the inclusion of Turmeric (“This spice is a staple of indian cuisine and has been widely studied globally” p185) and coconut (“populations which have traditionally consumed coconut - like the Tokelauans, who ate more than 30 per cent [sic] of their calorie intake in the form of coconut...”)
I don’t have a problem taking inspiration from different communities from around the world but the inconsistencies in use between the real Pioppi and that imagined and extolled by the authors are quite confusing.
The Role of Physical Activity
When it comes to physical activity, Malhotra is well known for an infamous editorial in the BJSM, “It is time to bust the myth of physical inactivity and obesity: you cannot outrun a bad diet” and in the Pioppi Diet, O’Neill and Malhotra repeat much of the same line standing on the shoulders of Tim Noakes who they say first, “dismantled the conviction that running marathons eradicated one’s risk of heart disease”
Once again, the narrative is often confusing throughout the book as there is a conflation of the physical activity terminology. They highlight the fact that the people of Pioppi never do any exercise, but it (almost) becomes clear that by exercise they mean scheduled exercise, or more specifically gym-based exercise. They refer to the concept of “meaningful movement” in a chapter titled “movement is medicine” yet never quite state whether this chapter title is ironic or a statement of the author’s belief. Comparisons are made between the average lifespan of Tour de France riders and the men of pioppi and cited as evidence that doing exercise does not mean you’ll live longer. Unfortunately there is not space on this page or time in my life to explain why this should not be the only comparison that we make in coming to this conclusion but yet it appears to be one of the main pillars of evidence used to support this thesis.
They highlight the importance of the exercise du jour, HIIT training (although to be fair O’Neill does point out that it has been around for many years in the form of “interval training”). O’Neill [they seem to take turns in writing chapters but there is a lack of explanation or warning of this) makes reference to Izumi Tabata’s seminal work on intervals but, as with many references to Tabata, fails to reinforce how hard a proper Tabata session needs to be and that few people that are not already active and fit should or would choose to do it.
They also make the common error of thinking that the only important aspect of Tabata training is that one moves for 20s and then rests for 10s before repeating. To gain the benefits from Tabata training, or HIIT, participants need to be working at very high intensities that are most often achieved by using a cycle ergometer. Appropriate warm-ups and cool-downs are required as are the monitoring of intensities. I fear therefore, that hanging on to the side of a door would not result in a meaningful HIIT session.
The HIIT phenomenon also offers an unforeseen opportunity for the authors to suggest that the only reason we don't know about this disruptive way of exercising is that it suffers from abuse in a very commercial multi-million dollar exercise industry. I honestly don’t know what this means.
The reference above to a Canadian study is not identified so could be a school project for all I know. Further issues surrounding the use of HIIT training for health can be found elsewhere (see Biddle & Batterham) but the lack of awareness and explanation of these issues is disappointing.
There is a chapter that goes into “detail” on the type of exercise that should be included in the 21 day plan which is “developed with and written by another author”, a point made at the start of the chapter and after reading the chapter in full this point felt more like a disclaimer than a credit. Anyone would be a fool to say that there is only one way to exercise and that there are not contested areas when it comes to what we recommend (I’ve got a long list of evidence and questions about physical activity guidelines elsewhere on this website). I can say with confidence, however, that I’ve never seen an exercise programme like it. One exercise a day for 21 days with no exercise repeated, no mention of how much of each exercise one should do although “each day of movement builds on the days before”. There’s also some of the strangest coaching points that I’ve seen written down in a long time.
The guidance that does exist on how much of each exercise one should do is within the “guiding factors” and includes advice such as “if your jaw and teeth are involved, the intensity of the movement sequence is above your normal”, “allow your arm and leg muscles to bear your weight” and my favourite, “listen to your bones they fit together in very specific ways”. The exercises themselves are all fairly standard yoga, pilates, tai chi and strength/conditioning activities with just one a day recommended and no timings, sets or reps. Much attention has been given earlier in the book to the unique benefits of HIIT and Tabata training so it’s with some surprise that in a twenty one day period there is only one session of tabata-style training recommended. This would be in contrast to widely used exercise protocols of 3 times a week for 12 weeks (See this by Gibala for instance). Maybe it’s because the old man in Pioppi village would only do one session of Tabata training every three weeks.
Here are a few of the gems included within the exercise guidelines:
- Dynamic squats - as you rise, press through the ball of the foot to activate calf pump, sending blood back up to your heart
- Chi (helicopter) arms - keep the gaze soft and the head balanced over the ribcage
- Squat - keep energy out the crown of the head and the sitting bones
- Plank to V - pull forward into a plank position that feels like it is flying
- Mountain climbers - breathe evenly and jump through your joints
- Dynamic crawling - allow your body to move forwards and backwards with natural intent
I’m reminded of Malhotra et al’s infamous mantra that “you cannot outrun a bad diet”, and I’d offer an additional phrase, “especially with a crap exercise programme”.
The book contains a lot of sensible advice but is undermined by two main issues. Too often the concept of naming a diet after a small village in Italy is brought into question, either by blindly using it as entire proof of concept or conversely, by completely ignoring the realities of life in an italian village and recommending everyone eat bucket loads of turmeric and coconut. The other, not unrelated issue is that there are too many statements throughout the book that are made with great confidence but which are completely unsupported by evidence. The author's could make the assertion that this is not an academic text and that too much information can disrupt the narrative but I would point anyone towards the work of Alex Hutchinson to see that it is possible.
I agree, for instance, with the sentiment that the role of physical activity is often over-emphasised in addressing obesity and that it’s importance is intentionally overplayed by the industries that are keen to sell us cheap processed food (I’ve written about it here) but I wouldn’t go as far as Malhotra in saying that the link is a lie entirely manufactured by the food industry. I haven't really touched on the issue of how low-carb the people of Pioppi actually are, or how low-carb the rest of us should be going but the way that the "evidence" was presented throughout the book on how the people of Pioppi led their lives, I saw no point in examining this content.
While much of the Pioppi talk is about lifestyle and long-term change my original assertion that the authors might have been stitched up by the publishers in being made to add the 21 day tagline was wrong. The book recommends nothing more than 21 days of healthy eating (lots of curry) and one Tai-Chi exercise a day. There is no content that suggests how those that follow the 21 day plan might prolong these changes to their lifestyle or any of the challenges that they might face. It’s been shown repeatedly in studies that any diet will work for a short period as long as the person monitors what they eat, aims to make changes and then makes changes. The complete lack of advice on maintaining long term behaviour change or recognition that it is a problem is one reason why this diet does sit firmly alongside other fad diets.
I’d love to hear the thoughts of the old man of Pioppi that we were introduced to in this book and find out his thoughts on being put through 21 days of living the lifestyle named after his hometown. I’m sure regular curried food, high intensity tabata circuits and spending time breathing would all feel most familiar to him.