Thank you. It's so nice to be here, and thanks to Mike for the introduction. I'm going to talk about food, and one of the questions I'm always asked is, how come a cardiologist became interested in food?
And now, actually, I'm the dean of a graduate school of nutrition science, and my answer is kind of only partially tongue-in-cheek. Why isn't every cardiologist doing only, predominantly focused on nutrition? This is the single biggest issue for health in our patients, and so if we really want to understand and treat...
cardiovascular disease, metabolic disease, diabetes, obesity, we have to understand sort of the science of food. In terms of disclosures, all my research is funded by federal and nonprofit agencies. I do give talks or have consulted for a range of companies kind of ad hoc. And I sit on some scientific advisory boards of some innovative companies that are trying to use food for health. I want to thank Dr. Kevin Graham for all of his leadership in this area for many years.
And thank you. I've heard that if we could create a song and he could sing this talk, he probably could sing it for me. So we have to set this to music sometime, and it must be frustrating for him, but also he must be honored and very proud for this lecture, and I'm very honored to give it.
So we really face a global nutrition crisis. That's not an understatement. Poor eating is the single leading cause of...
of poor health in the United States, exceeding tobacco smoking. And this is true globally. It's the single leading cause of poor health, almost all due to chronic diseases. Also, there's, of course, undernutrition and vitamin deficiencies.
This is also a major issue for disparities in hunger in this community and others. Of course, education and income and prejudice, all of those are the predominant causes of disparities in hunger, but there's still a vicious loop. And so kids and families with the worst, you know, access.
and ability to eat healthy food. Kids don't do well in school, parents get sick, and it leads to a vicious cycle and keeps people in poverty. As I'll show you and I'll discuss, this is absolutely decimating health care spending. I mean, we're talking about who's going to pay all of the arguments now in the Democratic debates, all the arguments a couple years ago when the Republicans were debating the Affordable Care Act, all the arguments 10 years ago were all about who's going to pay. Should it be the government paying?
Should it be private payers? Rather than how do we actually make us less sick and spend less? And so food is the single biggest opportunity for reducing health care spending. And this is true not only for government budgets, as I'll discuss, but also for private businesses.
Small businesses in our country say that rising health care premiums are their number one concern. And for large businesses, it's in their top three. And so this is crucial that we get this under control.
This is also, I'm not going to talk about this today, but this is also the biggest issue for sustainability and climate change. We've been talking about cars and, you know, turning off the lights and recycling for, you know, decades. And yet food and ag is by far the single biggest issue for sustainability on the planet.
About 30% of all climate change emissions are from food and agriculture. That's huge. About 70% of the world's water use is for agriculture. 90% of deforestation is due to agriculture.
stress to the ocean, stress to our soils, depletion of soils. If we want to fix, you know, climate change, it has to be through ag. And then lastly, it's really a crucial issue for national security.
And it's interesting that for millennia, major governments have cared about food because of national security. That's why governments have cared about having enough food for their population to have their military be able to fight. And this was true in this country until recently, and the government seems to have forgotten that. So You know, the birth of the recommended daily allowances, the RDAs, that are in the back of every package and drive global policy was 1941. That year is not an accident.
It was the National Nutrition Conference on Defense, ordered by President Franklin Delano Roosevelt to know what the population needed to go to war, and that led to the RDAs. And then the birth of the school lunch program was 1945. Again, not an accident. Through the draft, the number one cause of an otherwise qualified recruit not being able to join the military.
was poor oral health due to poor nutrition. And so Congress said, we can't have a country where we can't have people fighting. And so they created the National School Lunch Program. And now the number one medical reason that otherwise qualified Americans can't enroll in the military is overweight and obesity. Right now, 71% of young Americans can't qualify for the military.
Again, there's other reasons, too. There's crimes and not having a high school degree. But the number one medical reason is overweight and obesity. And so.
There's a group called Mission Readiness, which is about to come out with their third report. 700 retired generals and admirals who say that childhood obesity is a major national security threat. And the reason I put all this together is because if we just talk about health and well-being and hunger disparities, We're only going to convince about 10 or 15% of people that this is really important enough to make a difference. People care and talk about it, but they're not going to take action.
But if we add the unbelievable economic consequences, the environmental consequences, the national security consequences, this is a nonpartisan issue to fix this, right? And we need government, we need business, we need health care to fix this. And this is something we can actually all fix together.
This is just one analysis that we participated in. There's been several. doing comparative risk assessment to try to understand and model and estimate the causes of disease from different things.
This is in the United States. We have hundreds of thousands of deaths along the bottom axis. We have the, you know, modifiable causes. There are the colors are the types of deaths.
And so blue is mostly chronic diseases, cancers and cardiovascular diseases and diabetes. And you can see here that diet is, you know, the single leading cause of poor health. And so, you know, when we think about some of the great... tragedies facing our country.
You know, one of them, mass shootings, for example, in August this year, there were 53 deaths from mass shootings in the United States. It's a horrible tragedy, right? And we should prevent it.
There were 40,000 preventable deaths from poor diet, right, in August. So, you know, the comparison is so stark. And this has happened kind of slowly, and we all just kind of see it around us, and we think it's normal.
We are not living in the normal human condition, right? This is not okay. And we sort of have to wake up and kind of realize that and take action.
And so, you know, why is health care so expensive? We wrote an op-ed on this with Secretary Dan Glickman, former secretary of the USDA, a few weeks ago in The New York Times. There's two reasons health care is expensive, only two.
We have incredibly expensive technology and procedures and drugs, and we use them a lot. And we have really, really sick people in our population. It's those two things.
And so the only way to reduce health care is either to do a lot less. which is going to be very challenging given just kind of the levels of access and procedures that our country is used to, or we're going to have to get healthier. A hundred million Americans, almost half of every adult has diabetes or prediabetes.
Just think about that. Like half of adults in our country have diabetes or prediabetes. And since rates are pretty low, under 30, under 35, like over 35, it's much higher than half. 122 million have some form of cardiovascular disease including including hypertension and again just cardiovascular disease causes 2,300 deaths a day right look at the response to Ebola right there was an Ebola threat Congress had hearings there's all kinds of stuff done more than 2,000 people are dying every day from cardiovascular disease and not just people in their 80s right you guys know that and yet you know we're not taking action three and four adults are overweight and obese so more of us are sick than healthy right now that's Not normal, right?
This should not be normal. And as probably people have heard or may have not heard, longevity has declined three years in a row in the United States, right? That's never happened before.
People are living shorter lives for the first time in American history. And this is incredibly expensive. And I think this, to me, is the take-home message of why we're starting to see people really paying attention in the halls of Congress and in businesses. This is really expensive.
This is just federal healthcare spending. It doesn't include the state's shared cost of Medicaid, private insurance. You know, look at those graphs for Medicare and Medicaid from 2009 to 2016. This isn't a graph of like 50 years, right?
This is completely unsustainable. It's swallowing up every other priority that we have. It's 28% of the total federal budget and going up.
It's 30% on average of state budgets and going up. It's the top concern, as I mentioned, for U.S. businesses. Diabetes, direct and indirect costs.
330 billion per year, CVD, direct and indirect costs, 350 billion per year. And by one estimate, if you account for all of the different diseases related to obesity and the productivity losses, 1.7 trillion per year. And we throw those numbers around a lot, but it's good to put them in context, right?
So what's the NIH budget? Does anyone know what the NIH budget is compared to 335 billion for type 2 diabetes? 44 billion, right? the CDC's budget, about $15 billion.
The FDA's budget, about $15 billion. The entire Department of Education is $90 billion. What about the tax cut? The tax cut that was passed two years ago and was incredibly controversial, the biggest tax cut in history, driving up our deficit, you know, very controversial, $100 billion a year.
The entire tax cut was $100 billion a year. Just diabetes, which is almost entirely preventable through nutrition and people can be put into remission, is $335 billion per year. There's a lot been written about stagnation of wages in the United States.
You've probably heard this, that, you know, especially the lower 75% of American wages have been flat and stagnant over the last 30 years or even gone down in real terms. If you add in what all the businesses are paying for healthcare premiums out of pocket, that explains the whole thing, right? If you take wages plus healthcare, businesses are paying employees, but it's all going to healthcare, right?
This is squeezing out and crushing every single thing that we want to do in our society. And what's kind of amazing to me is the public gets this now in a very 60,000 foot way. They know the food is making them sick.
And especially millennials. I mean, I don't know how many people have kids, young kids who are saying, I'm not going to eat this. I'm not going to eat this way.
I'm changing my diet, right? I mean, people see this all the time, right? Millennials are absolutely revamping the system. They want health.
They want sustainability. They want authenticity. They're really, really shaking up the system in this country and other Western countries. But they're also incredibly confused.
People are really confused, right? They don't know what diet to be on, how often to eat, whether to take supplements. There's enormous confusion. And one take-home message, I guess, that I want to leave you with, I mean, one is that food is really important.
We should be doing something about it. But another one is there's a lot been written sort of in the lay press. And even by some... non-nutrition experts who are scientists that the science of nutrition is soft and squishy and changes.
And we've written extensively about this, but I'll assure you that it's not changing any more than cardiology or physics or genetics or any other science. And just think about cardiology and all the controversies that are going on. There's controversies about aspirin.
There's controversies about statins. There's controversies about who to give, you know, Who did you stable PCI in? There's controversies about the right anticoagulants.
Imagine if every blogger, every book author, every chef, every person around the table had their own opinion and was writing about these things and arguing about these things and multiplying them by 100,000 fold, right? Nobody would trust cardiologists anymore, right? Having controversies and changes in science is very normal. What's different about nutrition is it's public, it's cultural, it's social.
And when I... tell people what I do, almost everybody says, oh, that's really interesting. Well, you know, the real problem is dot, dot, dot.
And they tell me what's going on and why, you know, low-income Americans have worse diets. And it's because of this, it's because of that. And, you know, if I tell them about, you know, controversies over which stent to use, they're not going to say, oh, that's interesting. Let me tell you, right?
So there's something about nutrition that's very personal, of course. We all eat, but it's causing a lot of confusion, but it's also causing an opportunity for action. So, you know, what's right now kind of the major things that's going on? The policymakers are focused on a handful of nutrients, which is looking back to the past.
And I'm going to talk about that. And the public is focused, interestingly, on an entirely different set of sort of silver bullet, single word answers to the question. And neither is right. Neither is actually based on the current science right now.
And that's what I'm going to. kind of walk you through. And I have plant-based and vegetarian at the bottom.
That's a lot of scientists are talking about this now, plant-based. And I don't like plant-based or vegetarian or vegan as definitions of a healthy diet because they're only defined by what you're not eating. And you can still eat really, really bad diets on those diets. And so fries and a Coke are vegan, Oreos are vegan, gummy bears are vegan, every breakfast cereal in the aisle that's just...
is vegan. All those energy bars are vegan, right? And so most of what's bad in the food supply actually is vegetarian or vegan right now. It's all the starch and sugar and ultra processed foods.
And so you can have a really healthy diet that's non-vegetarian or vegan or a really bad one. And you can have a really healthy vegan diet or a really bad one. And so just saying plant-based is not, you know, really the right focus right now. So how did we get here? And I'll just go through this quickly, but I think it's actually really important because...
If you just step back and look at the history of the last, you know, 80, 90 years, it actually explains why we're here and why we're in the situation. And just people, you know, often just don't step back and look backward a little bit. You know, nutrition science is a really, really young field. Modern nutrition science is incredibly young.
I think it's probably the youngest, you know, major science there is right now. And we're rapidly learning, but there's a lot left to learn. I date the birth of modern nutrition science. to 1932, which is really, really recent, right?
1932 is not that long ago. This was the first time any vitamin was isolated and synthesized. The first vitamin wasn't even actually discovered until the late 20s, thiamine. But vitamin C was actually then discovered and isolated and synthesized in 1932. And for the first time ever, they proved that there was an active ingredient in citrus fruits that prevented or treated scurvy. That hadn't been really proven until 1932. And James Lind, a British seaman, had, in the 1700s, done the first recorded controlled trial where he gave different sailors different things.
And the one group... out of six that he gave citrus fruits to with scurvy, they improved. And so the British fleet started adding lime to the watered down rum of the British sailors.
And the British sailors became known as limeys, right? They're called limeys because of that. And the historians say that probably led to their domination of the seas for the next 200 years because of no scurvy. But not everybody did that.
Most countries didn't do that. Even the the British weren't sure that the citrus fruits were doing that until 1932, right? That's modern history.
That's really recent. And so there was this explosion of science in the 1930s, and it was called the era of vitamin discovery. It went from the 1930s to around 1950. All the major vitamins were actually discovered and isolated and synthesized.
And the accident that explains a lot about where we are is the accident of geopolitics, is what was going on at the same time was the Great Depression and World War II. And so I mentioned the RDAs, right? There was a huge concern and fear about food shortages and war and issues of deficiency.
And so all of the science and all of the kind of politics of the time to 1950 were all about getting the right reductionist approaches. What is the single vitamin or single nutrient to prevent and make me healthy? How do I get that into my food, right?
And that reductionist approach where you pick, you know, vitamin D for rickets or vitamin C for scurvy or thiamine for beriberi or vitamin A for night blindness, right? That single nutrient, single disease relationship works really, really well for a single nutrient clinical deficiency disease, right? That works really well.
And so at the same time in the 1950s, there was a lot of books written about the population explosion and increasing population of the earth and people were really worried about starvation. And so the focus from the 1950s on was let's create as much cheap, shelf-stable, starchy calories as we can so we avoid starvation. And let's fortify those foods with the right vitamins so that we prevent population vitamin deficiencies and we'll have a healthy population, right? Does that sound familiar? That is our food system.
The food system from 1950 to 2000 did exactly what we asked it to do, right? They created aisles of shelf-stable, cheap, starchy calories fortified with vitamins. Wasn't nefarious.
It wasn't industry trying to hook us. It was a very conscious attempt, the green revolution and all of these things. And it wasn't really until 1980 that the science really started focusing and the policy really started focusing on chronic disease, nutrition and chronic disease. 1980 is modern history, right?
That is not that long ago. That was the first dietary guidelines with recommendations for low-fat diets for cardiovascular disease, right? Until 1980, it was all about getting the right nutrients in the population. And so What happened is that same approach that had worked so well was unconsciously taken to chronic disease. Let's find the nutrients, the nutrients that causes disease, and let's take care of it.
So the nutrient for cardiovascular disease became saturated fat, right? If you lower saturated fat and cholesterol, those are the nutrients will be okay, right? Now we're doing the same thing for obesity, right? The reductionist approaches calories. It's just energy balance.
Let's just count calories. To me, telling a patient or... telling the population that your obesity is due to energy imbalance is like somebody coming with a fever saying, oh, you have temperature imbalance, right? Like that's not the fever.
It's a circular argument, right? What's causing the energy imbalance? Why are Americans, like a switch around 1985, 1990, why are we eating more?
Why do we have energy imbalance, right? We didn't have it in the 50s and 60s and 70s. This is not something that's led up slowly.
There's been changes to the food system. So this explains a lot. And It also explains this kind of messy middle we are in now where we're trying to, the science has moved away strongly from this reductionist approach for chronic diseases, but the policies are still kind of retrograde and focused on that.
And we're sort of have these two rivers mixing, this muddy river and this clear river mixing. The reductionist focus works great for nutrient deficiency diseases. This reductionist focus doesn't work for complex chronic diseases like cancer and diabetes and cardiovascular disease. And that's what we're learning.
And yet. I'm having trouble with the clicker here. And yet this really permeates US nutrition policy. So the National School Lunch Program in 2012, the Healthy Hunger-Free Kids Act, was a huge success.
So I want to say that really clearly. The Healthy Hunger-Free Kids Act dramatically improved school meals. And now school meals for most kids are the healthiest diet of their day. School meals are actually, the health has improved quite a bit.
A lot still could be done, but they're much better than they were. But one thing, one thing that I think was a mistake was whole milk. was banned, plain whole milk was banned, and chocolate skim milk is allowed, right? And I ask, well, why is that?
And they're like, oh, the dairy industry. The dairy industry doesn't care, right? They'll sell either carton of milk. It's because of this reductionist focus.
There's fat and saturated fat in whole milk. We can't give kids that, right? We should give them chocolate skim milk. The new nutrition panel was changed for the first time since 1990, just a couple years ago. One of the biggest changes was calories was really blown up, huge focus on calories, and also the portion size was changed.
The portion size was approximately doubled on different foods. And so if you look now at an ice cream, I think the portion size might be a half pint, and so the calories have doubled all of a sudden on your ice cream because they doubled the portion size. Restaurant menu calorie labeling, all changed now by federal law, over 20. have to have the calories labeled.
And so, you know, it makes sense to focus on calories if you're comparing two bad foods, right, two unhealthy foods. But what about if you're comparing a food that's healthy to a food that's not healthy, right? Is calories the right metric?
And I don't think so. I think you should always eat more calories of healthy food, 800 calories of healthy food and 600 calories of bad food, including for obesity long term. And so I think this, you know, some of these policies, again, are sort of backwards looking and two reductions.
And this is... definitely true internationally. It's even worse internationally.
All of this stuff, I don't know if you've heard about the chili black box label. All my public health colleagues are like breathless and so excited about what chili is doing. One of the best things that chili has done, they have the strongest, just passed about a year ago, by far the strongest food policy in the world. One of the best things they did is they removed all marketing to kids.
And so cereals can't use cartoon characters. You can't have any marketing to children of food of any kind. It's just been banned in the whole country It's kind of amazing the cereal aisle right all those pictures of Tony the tiger. They're all gone And then the other thing they did is they put these black box warning labels and so most aisles of the grocery store Everything has a black box warning label, but what is it based on calories saturated fat sodium and sugar? So, you know not to me like a holistic view of the food, but a very reductionist focused And so I'll show you I mentioned the science has changed rapidly.
This is the science of diet and chronic diseases, cardiovascular, diabetes, and obesity, looking at the publications in PubMed in every decade until the present. And of course, we're not done yet with the present decade. And you can see we're doubling the science. And so what we knew around 1980, when the low-fat diet was recommended, what we knew even around 2000 is nothing compared to what we know now.
And so there was a foundation of really important science. But most of what we've learned about diet and cardiometabolic diseases has been since 2000. And that has not yet been implemented into policy. It's not yet made it into the national consciousness.
And this is where we are today. So, you know, if I have to summarize big picture what we've learned about cardiovascular disease, I'll start with cardiovascular disease. These two trials really summarize everything. And there are people who say you can't learn anything from cohort studies. They're confounded and they're biased and epidemiology doesn't work and you have to do trials.
I'll just tell you that all the courts. studies show exactly what these two trials showed. So they're completely consistent. So what are these two trials? The Women's Health Initiative at the top, nearly 50,000 postmenopausal women.
It had a hormone replacement arm, which got a lot of attention, but it also had a low-fat diet arm. That was the prevailing recommendation of the day. So they randomized 50,000 women to a low-fat, low-saturated fat diet.
And at six years, they had substantial reductions in their fat intake, 8% energy reduction in their fat intake from about 37% percent energy down to 29 percent energy, almost a three percent reduction in saturated fat from about 12 and a half percent energy to nine and a half percent energy. Those are massive reductions. They basically met the guidelines, right?
And that's the curve for cumulative hazard of coronary heart disease. Absolutely no effect on coronary heart disease, right? They lowered their fat. They lowered their dietary cholesterol.
They lowered their saturated fat. No effect. No effect on incident diabetes.
No effect on home and insulin resistance. No effect on cancer, right? No effect of a low fat, low saturated fat. low cholesterol diet.
And that paper, I don't remember when it was published, 2004 maybe, right? And people probably don't know this, but the 2015 dietary guidelines for the first time, it took 11 years, said we should not be restricting fat anymore. The DRIs, which is set by the National Academies of Medicine, which is the RDAs, hasn't been updated since 2002. So that still says there's a 35% limit on total fat.
And that's what's on the back of the package and the FDA. So they're not the same, but the dietary guidelines, they don't restrict. total fat anymore for the first time.
It took 11 years to translate. In contrast, the PREDIMED study, this Spanish randomized trial, randomized about 9,000 people in Spain who already had a healthier diet than people in America to a controlled diet, which was sort of a low-fat American Heart Association diet, or a Mediterranean diet with adding nuts or extra virgin olive oil. And they gave them free nuts or gave them free extra virgin olive oil.
They're supposed to eat nuts every day. or a liter of extra virgin olive oil per week, a lot of fat. And what happened in that trial?
Well, fat went up by four and a half percent energy. It went up to about 40. 41, 42% calories from fat, no change at all in saturated fat. And there was a 30% reduction in hard endpoints, mortality, coronary heart disease, and stroke. There was also in secondary analyses, a reduction in waist circumference, a reduction in diabetes, a reduction in a couple of cancers.
And so this is kind of all you need to know about cardiovascular disease. If you focus on nutrients and you focus on lowering fat and saturated fat, no effect. If you focus on healthy foods and increasing healthy foods in particular, what... what I'm going to call protective foods. If you focus on increasing protective foods, especially those rich and healthy fats, you get dramatic reductions in cardiovascular disease, and that's about the effect of a statin, right?
30% reduction. That's a big, big effect. And so this is kind of what you need to know.
It's really about foods and increasing protective foods. What about, what other lessons have we learned? This is very, very tricky.
Okay. So, so big picture lesson number one. for obesity, which I think is really a big topic for today, is that you can't judge a food by its calorie count. Calories is a misleading metric for judging long-term risk of obesity. Short-term, of course, calories are king, but long-term, there's so many physiologic effects of foods.
Foods are information. We're not buckets with calories being poured in the top and calories being poured out the bottom. The foods create major physiologic changes in our brains and our microbiomes and our livers.
that ultimately change our long-term consumption of food and also change our actually energy expenditure. And there's trials now showing this. So I won't go into all of the details, but I'll show you just a couple of the papers.
So this is one paper, right? For decades, we've recommended low-fat diets for weight loss. And still, in a recent Gallup poll, 70% of Americans think lowering fat is the best approach for losing weight because there's more calories per gram in fat than in protein or carbs.
But there have been many, many trials. This is one of the best ones by Cox. a colleague, Iris Shai from Israel, randomizing obese or overweight people in a work site to a two-year trial with three different types of diets. And the diets were different in many ways, but I'm showing you their fat content. Everybody loses weight in the first three months on any diet, right?
Because they're paying attention and they're counting their calories and they're working hard. That's why all fad diet books sell, right? If you go on any diet you want for three months and you'll lose weight.
But inevitably, long-term, the body starts fighting back. And people kind of start to regain weight, although they're also lighter by quite a bit at the end of the trial. But in this trial, as in many other trials, the highest fat diet does the best.
Low is good, right? Weight loss. And so that's been seen again and again and again.
On average, high fat diets, you know, we say fatty foods all the time. But high fat diets, you lose weight more than in low fat diet. What about foods?
And so we looked at long-term weight gain. Long-term weight gain is very different from weight loss, right? So we looked at...
three different cohorts. Each color here is a different cohort. And we looked at long-term weight gain over 20 to 24 years in these cohorts.
Very, very gradual. And we said, how did people's changes in their diet relate to changes in their weight? What do people think the average weight gain is in the United States per year among adults? Five pounds a year. So the average person gains 25 pounds in five years.
That's a lot. The average person doesn't gain 25 pounds in five years. It's about half to one pound a year, the average weight gain, right?
Because five pounds, right, we gain 50 pounds in 10 years, right? The average, that's too much, right? It's about half a pound to a pound per year on average across the whole population, right?
But that's 20 pounds in 20 years, right? You're 18, you're pretty fit, you graduate high school, you're 38, you weigh 20 pounds more. You're 58, you weigh 20 pounds more, right?
That's the obesity epidemic, this slow, gradual weight gain for the vast majority of people. Do you think we could do a randomized trial for a year or two and try to understand that slow gradual weight? There's no way to do it, right? Do you think we ourselves have any idea what's causing that half pound weight gain of all of our dietary choices in a year?
We don't, right? So it's really hard to study. And what does that also tell you about our mechanisms for weight control? There's a lot been written about industries hooked us and we're in this toxic food environment and there's all this marketing and advertising and cheap food.
All that's true, but what does it tell you in that environment? How are humans wired for weight control? Is our wiring strong or weak?
I think our wiring is really strong, right? We have really subtle weight gain. We're almost keeping weight stable, but not quite.
And so what we wanted to study here is how do foods tip that balance long-term subtly? And so what we did is we studied the weight change associated every four years. This is the axis of the weight change every four years associated with increasing the intake by serving per day of all of these foods. And now... if calories were king and all that mattered was calories, if you increased intake of anything, you should gain weight.
All the bars should be to the right relative to. They're calories, right? And so what did we find?
That's not what we found. We found, you know, mostly starches and sugars in particular were linked to weight gain. Potato chips, potatoes, fries, including boiled baked potatoes, sweets and desserts, refined grains, and sugar-free beverages were all at the top. And there were some interactions. Meats were also linked to weight gain.
And butter, there were some interactions with bread. But mostly starch and sugar were most of the things related. weight gain.
And I just want to point out that the weight gain associated with Skittles was exactly the same as the weight gain associated with a bagel or special K or rice, right? Exactly the same, which is metabolically consistent with what we know about, you know, candy versus starch. And then there were foods that were pretty neutral, including cheese. And this is, you know, Americans. And so this isn't, you know, brie on a little plate with walnuts engraved, right?
This is the way Americans eat cheese on pizza and hamburgers and all this stuff. There's been books written, entire books, chapters written about cheese and obesity in the United States with no data that cheese is actually obesogenic. Cheese is a fermented food. And there's a lot of evidence about fermentation potentially helping the microbiome.
Cheese is the richest source of menoquinones, vitamin K2, which seems to be potentially beneficial against diabetes. Food is complicated, right? You can't just judge a food by its calories.
And so cheese seems to be neutral. Low-fat or whole milk seems to be neutral. And then there's kind of these magic foods that violate the laws of...
the more you eat, the less weight was gained, right? And vegetables, nuts, whole grains, fruits, and yogurt. And so this was 2011, seems like eons ago now that we wrote this paper. This was the first paper to sort of say that maybe it's not all calories, right?
Maybe there's other things going on besides calories. Maybe these foods affect our microbiome. Maybe yogurt has probiotics in it that affect our microbiome. That hadn't been studied in 2011. Maybe vegetables, nuts, whole grains, and fruits, the fiber caused...
satiety. Maybe there's low glycemic index. They displaced other foods.
And so long-term, you know, they help our mechanisms for weight control. These effects are very subtle, right? If you eat a serving of potato chips a day, every day versus none at all, you know, seven servings a week versus zero over four years, you gain a pound and a half. So that's about, you know, I have to do math quickly, 0.35 pounds per year, right? From eating potato chips every day.
It's very subtle. So mostly we're compensating. We almost perfectly compensate for the calories in potato chips and sweets and desserts and refined grains and soda, but not perfectly. And we almost compensate for eating more calories from those healthier foods, but again, not perfectly in a good way. We eat those foods and we eat a little bit less calories from other things.
And so it's really about complexity and it's not all about calories. And there's been many studies since then. This is a meta-analysis of randomized trials of probiotics. I'm looking. I think all but one published after our paper.
So this is all new science. And these are not big trials. They're not the best trials.
We need more, but there's about a thousand total subjects studied. And they usually give yogurt with or without probiotics or cheese with or without probiotics. There's probiotics in the rinds of cheese or pills. And if you do a meta-analysis, probiotics lower BMI, they lower weight. In a separate meta-analysis, they improve insulin resistance, confirming that there's more to food than just its calorie count.
And this is a really nice trial too, which you may have heard about. It sort of made its way into the media. This was by Kevin Hall.
He put people in a metabolic unit and gave them access to food to eat ad libitum for two weeks and then switched them over to the other diet. And the diets were mostly indistinguishable in terms of available calories, fat, fiber, sugar, protein, carbs, kind of all the basic macronutrients. The big difference was processing. And so one diet was ultra processed.
you know, really commercially processed foods. And the other diet was made sort of from natural and more whole ingredients. They weren't as different as you'd think again, because they were again matched on available calories, fat, carb, protein, fiber, and sugar. And what happened is without trying to, people ate, the same people, because this was a crossover trial, they ate about 500 calories more per day on the ultra processed diet than on the processed food diet.
And without trying to, they gained about a kilogram over two weeks. on the fully ultra-processed diet, and they lost about a kilogram over two weeks on the unprocessed food diet. So again, showing that you can't think just about calories, it's complicated.
So lesson number two, I've just talked about obesity for a few slides. Lesson number two, this is not just about obesity. You know, in the 80s, we were so focused on blood cholesterol. Blood cholesterol was the reason we had dietary guidelines for cardiovascular disease, that it led to oversimplification and focus on low-fat, low-saturated fat diets.
tackle just total cholesterol, not even thinking about HDL and LDL. Now we're so focused on obesity that I hear people talk about obesity and diet interchangeably, as though if you come in to your doctor and you're thin, your diet's pretty good, you're fine. You come to your doctor and you're overweight, obese, oh, you got to work on your diet, right? Obesity is just one minor pathway for the risk of nutrition. Minor.
It's a minor pathway. It is not the major pathway by which diet affects health. It's one pathway for sure, a major pathway for type 2 diabetes, but for all of health, for cardiovascular disease in particular, it's a minor pathway.
All of this is from randomized trials. You know, this is just a summary. And I think this is in the Braunwald chapter, if I recall correctly. So I write the nutrition chapter in Braunwald. If you're interested, you can read some of the details.
But nutrition affects every single pathway here, right? So we have to take the big picture view. And obesity is not the endpoint, right? Preventing obesity. The endpoint is cardiovascular and metabolic health.
And I'll just, you know, again, show you why this matters, because there's things beyond obesity. As I told you, cheese seems to be pretty neutral for weight gain, but pretty consistently, this is quintiles of consumption. The blue bars here are quintiles, so quintiles of milk, quintiles of yogurt, quintiles of cheese. And this has been seen in many studies.
Both yogurt and cheese are linked to low risk of diabetes, even though cheese seems to be kind of neutral for weight gain. Why might cheese lower diabetes? And if there's confounding, these are observational studies.
But if there's confounding, it should be in the other direction, right? People who eat cheese generally have worse diets, not better diets. And so, again, this is a place where if there's residual confounding, this should be even stronger. So we've written about this, and, you know, I'm not sure.
I don't know for sure that cheese reduces risk of diabetes, but there's so many interesting mechanisms that are going on. I mentioned fermentation that creates vitamin K2, menoquinones, which activate osteocalcin and other proteins. There's... specific medium chain and branch chain and natural ruminant trans fats in dairy fat.
Milk fat globule membrane is a really interesting molecule that basically, how you make butter is you destroy milk fat globule membrane, which is the normal phospholipid membrane, which circles the dairy fat. That's why raw milk, the fat floats to the top because this milk fat globule membrane. Milk fat globule membrane, there was just a trial done where in Europe where they gave a randomized trial they gave cream cheese at three different doses of milk fat globular membrane that was enriched with these phospholipids and The highest milk fat globular membrane cream cheese lowered blood cholesterol by 10% lowered LDL by 10% So they were getting cream cheese and their cholesterol went down by 10% and it binds cholesterol and goes to the microbiome So if you eat dairy that's not been ultra homogenized and not butter. Butter actually destroys most fat-glazed membrane on purpose, so you can turn it into a block. You know, it might actually have cholesterol lowering effects.
There's so many interesting pathways and so this review that we wrote in Circulation Research just last year, you know, again, I don't know for sure that cheese lowers risk of diabetes, but there's a lot more going on than obesity and weight when you think about health. So lesson number three, and I mentioned this term before, is we have to focus on protective foods. There's a, there, people say Often at the end of my talk, someone says, if I hear what you're saying, it's eat everything in moderation.
That's not what I'm saying, right? I'm not saying eat everything in moderation. Eat everything in moderation is an industry message to eat everything and anything you want and just kind of eat it in moderation, whatever that means, right? It's nutritional nihilism, right?
Do whatever you want. I'm saying there's good food, there's winners that we've got to maximize and eat much more of. There's bad foods, there's losers that we have to cut down on, right?
That is not eat everything in moderation. We have to eat much, much more of protective foods, fruits, nuts, fish. vegetables, plant oils, whole grains, beans, and yogurt. There's neutral foods. Cheese, maybe a little bit better than neutral.
Unprocessed meats, a little bit worse than neutral, probably because of the heme, heme iron. A lot of heme iron seems to increase risk of type two diabetes. People with hemochromatosis get type two diabetes.
If you actually bleed them, their type two diabetes improves. Women with gestational, women who are at higher risk for gestational diabetes, they have higher iron storage before pregnancy. There's a lot of interesting mechanistic evidence about heme iron. And I mention that because the Impossible Burger, what's the thing they're most proud of to make the Impossible Burger taste like meat? They put heme iron into the burger, right?
They put the one thing back that's probably the harmful thing for you for diabetes back into the Impossible Burger. So it's better for the earth, but it's not better for your health to eat an Impossible Burger. But in any case, there's mostly neutral foods. And neutral is okay. We can't always be eating the best possible thing on the planet.
Like, neutral is okay. But we got to be mostly eating the protective foods. And the worst foods is the refined grain starches and sugars, right? The plant-based refined grain starches and sugars. That's the worst thing in our diet.
It's about 40% of calories, right? Almost half of our calories are from refined grain starches and sugars. And I really am emphasizing, if you haven't heard me, starches, because it's the hidden sugar.
There's much more starch in the food supply than sugar. And so, you know, tons of refined sugar is not a good thing for you. But...
Don't forget starch, right? Don't get misled and think that foods without sugar are fine. And then processed meats are carcinogenic and also increase risk of stroke and other highly processed foods.
And if you kind of put all these foods together, I sort of, you know, looked at this a couple of years ago and I said, you know, what links these foods together? And other than fish, which has omega-3s and yogurt, which is probiotics, you know, mostly what these are is foods that give rise to life, foods that you can plant in the ground, you know, after weeks you know, being run over by a tractor in a desert. And if you give it the right conditions, they'll nurture a new plant life, right? Even vegetables are mostly fruits, right?
That give rise to life, eggplant, pumpkin, avocado, cucumbers, tomatoes. I mean, most vegetables are actually fruits as well. And so I think what, you know, the thousands of flavanols and phytochemicals and other bioactive compounds in those foods that nurture that new plant life, that's what our bodies need with aging. And we're just...
barely scratching the surface of the effects of flavanol, things that are in cocoa and green tea, these trace compounds. And so I think that's probably the biggest reason that those foods are good for us is those effects. And then there's many, many other questions, many, many other things we need to learn.
There's a lot of stuff not on this list. Garlic's not on the list. Turmeric's not on the list. I mean, there's all kinds of things that we don't really know that much about yet. We have to learn much more about the gut microbiome, about these phenolics and bioactive.
much more about individual healthy fats. The effects of food processing, I mean that trial I showed you by Kevin Hall is one of the first trials ever of food processing, right? We know so little about food processing. Additives, emulsifiers, and stabilizers, and all of these compounds that in really early evidence could be harmful, maybe are, maybe are not, very little information on them, lots of interest in personalization, but not tons of data yet to support it.
And then all kinds of diseases beyond cardiovascular disease, allergies, autoimmune conditions, cancer, brain health. There's so much we don't know yet about food and nutrition. And so take home message again is it's about healthy foods and it's mostly about food, not a reductionist focus. And this reductionist focus leads us in strange directions, right? Low calorie, less weight gain, fat-free, healthy, low saturated fat, healthy, vitamin-fortified, good for you, which is not true, right?
And these are all examples of weird products. What is in fat-free salad dressing? right? Like how many people have ever had low-fat or fat-free salad dressing, right? Like why would we do that?
Like oil is good for us, right? Soybean oil, canola oil, olive oil, that's what it is. That's really, really good for us.
Good for weight gain, good for diabetes, good for cardiovascular disease. Why would we ever eat low-fat salad? What's in low-fat salad dressing?
Sorry, non-fat salad dressing. It's an oxymoron, right? What's in non-fat salad dressing? Starch, sugar, and salt, right?
And a bunch of chemicals and stabilizers, right? So definitely don't eat that, right? It's not good for you. Baked potato chips, my other example, right?
Potato chips are not a health food. I'm not saying they're a health food, but if you're going to eat potato chips, they have three ingredients, right? Canola oil or soybean oil or avocado oil, really, really awesome and yummy. Starch and salt, that's it, right?
The only healthy ingredient is the oil. The oil is actually good for you. Unsaturated fat, maybe some phenolics if it's a decent, decent oil, but for sure unsaturated fats, it's actually good for you. So if you're going to eat the potato chip, get the highest. fat when you can, dip it in oil, eat it with avocados, right?
Lower the glycemic index is better for you, right? So don't eat baked anything, right? Eat high fat things that are made with healthy oils.
And then lesson number four that I want to get to in the last five minutes is that we've learned is that to really make behavior change, it's not going to be about education and telling people in dietary guidelines. It's systems changes, right? And this is a slide showing, you know. all of the influences on our dietary choices.
Even, you know, the wealthiest and most, you know, highly educated Americans don't have free choice in the food system, right? You eat what's around you. And for sure, if you get to lower income Americans, this is a huge problem.
But all of these are levers. And so all of these are levers that have been actually, you know, created mostly to create the food system, as I mentioned, the way we wanted to create it, a food system that, you know, prevented hunger and gave vitamins to the population. But all these now are levers. And so this is what we're working on a lot at Tufts. And we're going to Congress.
We're going to businesses. We're forming business councils to talk about this. This has been a major focus the last three years is we're putting together the evidence and the science supported by NIH and other grants.
And the Rockefeller Foundation is supporting this. And this is kind of our map of the best by policies and the things we need to do. There is no one silver bullet. Right. And we're actually coming out now.
with a set of recommendations putting together a bunch of organizations, and we have about 55 policy recommendations for changing the food system, we have to do all of them, right? There's not going to be one thing. This is a wicked complex system, as they say in Boston.
But there's things that are kind of obvious. And so... The National Institutes of Health doesn't have an institute focused on the number one cause of poor health. All right. We need a national institute of nutrition.
We need leadership, structure, funding to figure out all the things that we don't know and don't yet understand. In health care, we need to have nutrition in the electronic health record. Again, the number one cause of poor health is not an electronic health record. Right.
We don't track it. We don't measure it. Right.
That explains a lot. Healthy food prescriptions. If people heard the Geisinger health experiment where they gave fresh, healthy produce to their poorly controlled type 2 diabetics who were food insecure, which was 28% of all their diabetics were food insecure and had uncontrolled diabetes.
They gave them healthy food prescriptions in the healthcare system. They gave them free produce to take home, right? Over a year and a half, their hemoglobin A1c dropped from 8.1 to 6, right?
These were patients they couldn't control in any other way. Spending on those patients went down from about $250,000 a year to $50,000 a year. And the CEO of Geisinger Health was......with... snapped up by Google a few months after they published that and he's leading their entire new health care strategy now, right? They saw the dollars.
They're like, you saved $200,000 in diabetes? Diabetes is about one in four dollars in health care, right? This is a big issue.
So if you guys don't do healthy food prescriptions, you should think about this. Medically tailored meals I'll talk about. You guys should also do this for heart failure.
There's a lot to do. So I'll show you just some examples. Have people heard of medically tailored meals?
These are really interesting. People who have very complex chronic disease. Most of the inpatients we see, right, the patients that you admit them, how are you doing, Mr. Smith? You were just admitted four months ago, you were just admitted six months ago, you're in and out of nursing homes, right?
People with cancer, end-stage renal disease, heart failure, AIDS, right? These are the sickest patients in the healthcare system. There's been many, many studies now showing that if you give them meals at home, usually about 15 meals per week, for them and their whole families, healthy, medically cared meals with a dietician, you dramatically reduce healthcare utilization.
And so this is just one analysis that was published. There's been about seven. They use the Massachusetts All Payers Database, and they match them incredibly well in a lot of ways. They reduce hospital admissions by half.
They reduce nursing facility admissions by half, net savings of $10,000 per patient per year after accounting for the cost of the program. Number needed to treat, right? We love this in cardiology. Two patients with medically tailored meals to save one hospital admission, one patient for medically tailored meals to save.
save a nursing home admission. It's unbelievable, right? And because of this, there's strong interest in Congress in directing Medicaid to pay for medically tailored meals. California is doing a $6 million medically tailored meal pilot. You guys should be doing this in heart failure.
You have a foundation. You should be connecting with these organizations. I'm happy to connect them.
You should test this in heart failure. Just do pre-post. Take your low-income heart failure patients that are in and out of the hospital all the time and hook up with one of these organizations. I think MANA is doing this mailed.
So they can do mailed medically tailored meals. Protist prescriptions, this is the Geisinger Health experiment. So I won't go into too much.
It's pre-post. It's not, oh, and I should have mentioned that San Francisco General, Zuckerberg San Francisco General, is now doing a randomized trial in heart failure of medically tailored meals. It's been completed.
I haven't seen the results, but I've heard through the grapevine that it was exactly the same. In a randomized trial, about 50% or more reductions in hospitalization. This is a healthy protist prescription. So these aren't people that are quite as sick.
They can. you know, buy and cook food. Dramatic improvements. These are the improvements in all these outcomes.
We did an analysis of this. What if every adult, not just really sick adults, what if every adult in Medicare and Medicaid, you know, with their Medicare or Medicaid card could go to the grocery store and get a 30% discount on fruits and vegetables, right? What if we gave this produce prescription to everybody? How much would it cost?
How much health would it save? And so we did a micro-simulation model, and these are the cost-effectiveness. numbers, the incremental cost-effectiveness ratio, the dollar spent per life-year gain, and red is Medicaid, black is overall, you know, they're all in there.
You can look at the black, that's the overall health savings. Anything less than $150,000 per quality adjusted life-year gained is thought to be cost-effective. So all of them are cost-effective with cost-effectiveness improving over time. And I just show you that at 10 years, the cost-effectiveness of this is $37,000 per quality. which is almost exactly the cost effectiveness of statins for primary prevention, right?
So this is a best buy, and we should be doing this. And this is if you just give it to everybody, all the adults, let alone people who are quite sick. I'll skip this for time. This is about food stamps.
There's definitely ways to leverage food stamps for better health. And I just want to end with this note that what's exciting is business gets this now, mostly because of how millennials are pushing business. And these are the two canaries in the coal mine why business gets this and is at least trying.
to innovate for health and sustainability. Kraft Heinz was bought by 3G. 3G is this kind of ruthless cost-cutting Brazilian venture capital firm.
They bought Kraft Heinz about 2016, and they said, you know, we're all about profits. You guys are inefficient. We're going to run this as a business. You know, forget innovation.
All we want to do is make your product at the cheapest cost and get them out and slash costs, and we're going to make money. Look what happened to their stock. 70% decline in their stock. They announced a $15 billion write-off earlier this year, the biggest corporate write-off in history. And then Beyond Meat on the other end of the spectrum, super innovative, definitely good for the environment.
Beyond Meat doesn't have heme. I don't know if it's good for better for you than meat. I suspect it's not, but it certainly at least has that aura.
Thirty three million dollars of annual sales, zero profit. They have a market cap of six billion dollars. Right. So the industry sees this and they're really excited about trying to capture this move towards health and sustainability. So.
I think I'll end there for time. I want to leave time for questions. But, you know, what I've tried to outline is we have to link and integrate the science for what we should eat with the science of what the good policy, right? If we don't do those two things, you know, if we have just science and don't translate it, that doesn't help anybody.
And if we have policies that we're setting based on outdated science, it doesn't help and could actually hurt. And if people are interested, either for themselves or for their patients, we have a monthly newsletter. People always ask, how can I get more information? Where can I read about this stuff? We have a monthly newsletter that comes out.
It's online or print. The Tufts Health and Nutrition Letter, very well respected, written for the layperson, covering all kinds of things that you want to know or the patients want to know. Do protein bars work? Should I have supplements?
Intermittent fasting? Coconut oil? All the different questions people have. And I recommend this for further reading. So thank you very much and happy to answer any questions.