Book Review: The Pioppi Diet

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.