thank you it's so nice to be here and thanks to Mike for the introduction I'm going to talk about food and you know one of the questions I'm always asked is how come a cardiologist became interested in food and actually I'm the Dean of a graduate school of nutrition science and you know my my answer is you know kind of only partially tongue-in-cheek wise in every cardiologist you know doing only you know predominantly focus on nutrition this is the single biggest issue for help in our patients and so if we really want to understand and treat cardiovascular disease metabolic disease diabetes obesity we have to understand through 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 said on some scientific advisory boards of some innovative companies that are trying to you know use food for health I want to thank dr. Kevin Graham for all of his leadership in this area for many years and I've heard that if we could create a song and he could sing this this to talk he probably could sing it for me so we have to set this to music sometime and and you know I it must be frustrating for him but also you must be honored and very very proud for this lecture and I'm very honored to give it so you know we really face the global Nutrition crisis that's not an understatement you know poor eating is the single leading cause of poor health in the United States exceeding tobacco smoking and this is true globally it's the single leading cause for health almost all due to chronic diseases also there's of course under nutrition and and the vitamin deficiencies this is also a major issue for disparities in hunger you know in this community and others of course education and income and prejudice all those are the predominant causes of disparities and hunger but there's still a vicious loop and so kids and families with the worst you know i'm 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 like this is absolutely decimating health care spending I mean and we're talking about you know who's going to pay all of the arguments now in in the Democratic debates all the arguments a couple years ago when the Republicans were debating before with Care Act all the arguments ten years ago well all about who's gonna pay right should it be the government paying to be private payers rather than how do we actually make us less sick and spend less right and so food is the single biggest opportunity for reducing health care spending and this is true not only for government budgets as all discussed but also for private businesses small businesses in our country say that you know rising health care premiums are their number-one concern and for large businesses it's in their top three and 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 uses for agriculture 90% of deforestation is due to agriculture stress to the ocean stress to our soil depletion of soils if we want to fix fixed you know climate change it has to be through AG and then lastly it's really a crucial issue of her national security and 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 allowance is the RDAs that are in the back of every package and drive global policy was 1941 that year is not an accident it was a 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 the through the draft the number one cause of otherwise qualified recruits not being able to join the military was was poor oral health due to poor nutrition and so Congress said we can't have a country or we can't have people fighting and so they traded a national school lunch program and now then one medical reason that otherwise qualified Americans can't enroll the military's overweight and obesity right now 71% of young Americans can't qualify for the military again there's other reasons too there's 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 seven hundred 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 in hunger disparities we're only going to convince about 10 or 15% of people that this is really important enough to make a difference not 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 and national security consequences this is a non partisan 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 the colors are the types of deaths and so blue is mostly chronic diseases cancers and cardiovascular disease and diabetes and you can see here that 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 the 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 we should prevent it there were 40,000 preventable deaths from poor diet right in August so so you know the comparison and is it's so stark and and this has happened kind of slowly and we all just kind of see it around us and we think it's normal that we're not living in the normal human condition right this is not OK 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 Bookman 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 those two things and so the only way to reduce health care is either do a lot less which is going to be very challenging given this kind of the the levels of access and procedures and that that our countries used to or we're gonna have to get healthier a hundred million Americans almost half of every adult has diabetes or prediabetes I 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 one hundred and twenty two 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 we shouldn't this should not be normal and as probably people have heard of may have not heard longevity has declined three years in a row in the United States right this never happens where 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 and why I'm starting to see people really paying attention in the halls of Congress and in businesses this is really expensive this is just federal health care 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 percent 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 US businesses diabetes direct and indirect costs 330 billion per year CVD direct and indirect cost 250 billion per year and by one estimate if you account for all of you know the different diseases related to obesity one points and and the productivity losses one point seven trillion per year and we throw those numbers around a lot but I just you know 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 three hundred and fifty five billion for type two diabetes forty four 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 the tax cut the tax cut that was passed two years ago an incredibly controversial the biggest tax cut in history driving up our deficit you know very controversial one hundred billion a year the entire tax cut was 100 and billion billion a year just diabetes which is almost entirely preventable through nutrition and and people can be put into remission it's 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 seventy-five percent of American wages have been flat and stagnant over the last thirty years or even gone down in real terms if you add in what all the businesses are paying for health care premiums out-of-pocket that explains the whole thing right if you take wages plus health care businesses are paying employees but it's all going to help all 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 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 gonna not gonna eat this I'm not gonna 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 died to be on how often to eat whether to take supplements there's enormous confusion and one one one take-home message I guess is that I wanted 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 who are scientists that the size of nutrition 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 this controversy is about aspirin there's controversies about statin there's controversies about who to give you know who didn't do stable PTIN there's controversies about the right anticoagulant 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 a hundred thousand fold right nobody would trust cardiologists anymore right having controversies and changes in science is very normal what's different about nutrition isn't public its cultural its social and when I tell people what I do almost everybody says oh that's really interesting well you know the real problem is and they tell me why what's going on and why you know low-income Americans reports diets and it's because of this it's because of that and you know if I was if I tell them about you know um controversies over which stent to use they're not going to say oh that's interesting let me tell you right so 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 it 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 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 you know kind of walk walk you through and I have plant based in vegetarian at the bottom that's a lot of scientists are talking about this now plant-based and 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 diet on on those diets and surprised in a coke or vegan Oreos or vegan gummy bears or vegan every breakfast cereal in the aisle that's just 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 the right focus right now um 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 why were in the situation and just people like 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 um I think it's probably the youngest you know major science there is right now and we're rapidly learning there's a lot left to learn the ID 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 in 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 right that hasn'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 water down rum of the British sailors and the British sailors became known as limeys right they're called lime means because of that and historians say that probably led to their nation of the of the siege for the next 200 years because of no scurvy but not everybody did that most countries didn't do that even the British were ensure that the citrus fruits were doing that until 1932 right that's modern history that's really recent and so there's this explosion of science in the 1930s and it was called the era of vitamin discovery went from the 1930s to around 1950 all the major vitamins were actually discovered in isolated and synthesized and the accident that the accident had explains a lot about where we are is is the accident of geopolitics is what was going on at the same time was the Great Depression in World War two as I mentioned the RDAs right there there was a huge concern and fear about food shortages and war and 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 vite 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's works really well and so at the same time in the 1950s there was a lot of books written about the population explosion and and you know 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 vitamin so that we prevent population vitamin deficiencies and we'll have a healthy population right does that sound familiar right 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 it wasn't the Farias it wasn't industry trying to hook us is 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 chronic disease nineteen eighty is modern history right that is not that long ago that was the first i-tree guidelines of recommendations for low-fat diets for cardiovascular disease right until nineteen eighty was all about you know getting 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 nutrient that causes disease and let's take care of it so what the nutrient for cardiovascular disease became saturated fat right if you're lower size your fat and cholesterol those are the nutrients we'll be okay all 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 you know for me telling a patient or telling the population that your obesity is due to energy imbalance is like somebody coming with a fever they know you have temperature imbalance right like that's not like that's the fever it's a circular argument right what's causing the energy about why are Americans like a 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 fifties and sixties and seventies this is not something that's led up slowly there's been changes to the food system so so this explains it a lot and it also explains this kind of messy middle we are and now we're trying to the science is moving away strongly from this reductionist approach for chronic diseases but the policies and are still kind of you know retrograde and focused on that and we're sort of has these two rivers mixing this muddy river and this clear river mixing the reductionist focus works great for nutrient deficiency diseases that this reduction focus doesn't work for complex chronic diseases like cancer and diabetes and pro-v vaster 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 wasn't was a mistake was Holden was was band playing all Nova's van and chocolate skim milk is allowed right and I ask well why is that not like oh the dairy industry mr. doesn't care I think they'll sell either either carton of milk it's because of this reductionist focus there's fat in saturated fat and 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 with calories has really blown up huge focus on calories and also the portion size has changed the portion sizes approximately doubled on different foods and so if you look now at an ice cream I think the portion size might be a path pint and so the calories have doubled all of a sudden on your ice cream because they double the portion size restaurant menu calorie labeling all chains now by federal law over 20 have to have the the calories label and so you know it makes sense to focus on calories if you're comparing to bad foods right to unhealthy foods but what about that you're comparing a food that's healthy to a food that's not healthy right if 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 foods 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 to reductions and this is definitely true internationally it's even worse internationally I'm all of this stuff I don't know if you've heard about the Chile black box labeled all my public health colleagues are like breathless and so excited about what Chile is doing one of the best things that Chile has done they have the strongest just passed by the year though by far the strongest food policy in the world but one of the best things they did is they removed all marketing 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 countries kind of amazing the cereal aisle right all those pictures of tonita Tigers 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 is cardiovascular diabetes and obesity looking at the publication's 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 new around 1980 when the low-fat diet was 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 cardio metabolic 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 are confounded in their biased and epidemiology doesn't work and you have to do trials I'll just tell you that all the courts that he show exactly what these two trials showed so they're completely consistent so what are these two trials the the women's health initiatives at the top you know 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 ran like 50,000 women to a low fat low saturated fat diet and at six years they had substantial reductions in their fat intake eight point eight percent energy reduction their fat intake from about 37% energy down to 29% 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 have a cumulative hazard of courting her disease absolutely no effect on coronary disease right they load the fact that they lower their dietary cholesterol they lower 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 that 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's 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 Preda med study this spanish randomized trial randomized about 9,000 people in spain who already had a healthier diet and 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 leader 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 forty forty-one forty-two percent calories from from fat no change at all in saturated fat and there was a 30% reduction in hard endpoints mortality corn heart disease and stroke there was also in secondary analyses or reduction waist circumference reduction in diabetes the 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 gonna call protective foods if you focus on increasing protective foods especially those rich and healthy fats you get dramatic reduction in cardiovascular disease and that's about the effect of a statin all right 30 percent reduction that's a big big effect 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 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 this is the calories is a misleading metric for judging the 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 foods or information we're not buckets with you know calories being poured in the top and and calories then put out the bottom the foods create major physiologic changes in our brains and our microbiomes and our liver that ultimately change our long-term consumption of food and also change our actually energy expenditure and there's there's trials now showing this so I won't go into all the details that'll show you just a couple of the papers so this is one paper right for decades that we've recommended low fat diets for weight loss and still in a recent Gallup poll seventy percent 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 were in many many trials this is one of the best ones by colleague Irish high from Israel randomizing obese or overweight of people in a worksite to a two-year trial with three different types of diets and the diets are 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 a fad diet book sells right you could go on any diet you want for three months and you'll you'll lose weight but inevitably you know 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 as that's been seen again and again and again on average high fat diets you know we'd say fatty foods all the time but high fat diets you lose weight more than in low fat diets 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 color and we looked at long-term weight gain over 20 to 24 years in these cohorts very very gradual we said how did people change it in their diet relate to changes in their weight well where people think the average weight gain is the United States per year among adults five pounds a year so the average person gains 25 pounds in 5 years that's a lot I don't the average person to the game 25 pounds in 5 years it's it's about half to one pound a year the average weight gain right because 5 pounds right that you know we begin 50 pounds in 10 years right that 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 Highschool you're 38 you weight 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 can do a randomized trial for a year or two and try to understand that slow gradual weight though 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 you know we're in this toxic food environment and there's all this marketing advertising and cheap food all that's true but what does it tell you in that environment how are humans wired for weight control are they are is our wiring strong or weak I think I'm wearing is really strong right like we have really subtle weight gain we're almost keeping weight stable but not quite and so what we want to study here is how to food 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 is 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 with calories if you increase intake of anything you should gain weight all the bars should be to the right relative to their calories right and so what did we find us not 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 sugars free beverages were all at the top and there were some interaction meats were also linked to weight gain and butter there are some interactions with with bread but mostly starch and sugar were most of the things related to 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 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 and grapes right this is a merit way Americans eat he's on pizza and hamburgers all the stuff there's been books written entire books chapters written about cheese and obesity in the United States there's no data that cheese is actually obesogenic cheese a fermented food and there's a lot of evidence about fermentation potentially helping the microbiome she's the richest source of menaquinone vitamin k2 which seems to be potentially beneficial against diabetes food is complicated right you can't just judge a food by calories and so cheese seems to be neutral low-fat or whole milk seem to be neutral and then there's kind of these magic foods that violate the laws of thermodynamics 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 is 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 hasn't been studied in 2011 you know maybe vegetables not whole grains and fruits the fiber causes the taya tea maybe there's low glycemic index they displace 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've been asked 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 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 who do we need a little bit less calories from other things and so it's really about complexity and and it's not all about calories and and there's been many studies since then this is a meta-analysis of randomized trials of probiotics I'm looking I think all that one published after our paper so this is all new science and these are not big trials they're not the best trial you know 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 and the rinds of cheese or pills and if you do meta analysis you know probiotics lower BMI like they lower weight in a separate meta-analysis they improve home and insulin resistance confirming that you know there's more to food than just a calorie count and this is a really nice trial to 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 switch them over to the other diet and the diet's were you know 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 food and the other diet was made sort of from from natural and more whole ingredients they weren't as different as you think again because they were again matched on available calories at carb protein fiber and sugar and what happened is without trying to people ate the same people because this was a crossover child 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 process 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 is not just about obesity you know in the 80s we were so focused on blood cholesterol what 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 to 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 you know interchangeably as though if you're if you come in to your doctor and you're thin your diet is pretty good you know you're fine you're coming your doctor and you're over it 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's 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 randomised trials yeah you know this is just a summary and I think this is in the bran world chapter if I recall correctly so I write the nutrition chapter in bran mold 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 at the endpoint is is a cardiovascular 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 of the blue bars here or quintile so quintiles of middle quintiles of yogurt quintile of quintel's of cheese and this has been seen in many studies both yogurt and cheese are linked to low risk of diabetes even the chief 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 worse died it's not better diet 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 that creates vitamin k2 menaquinone which activates osteocalcin and other proteins there's specific medium chain and branch chain and natural ruminant trans fats in dairy fat milk fat globule membrane it's a really interesting molecule that basically what how you make butter is you destroy milk fat globule memory which is the normal fossil with the membrane which circles the the dairy fat that's why raw milk you know the fat floats to the top because you know at this Motaba membrane note saibaba remember and there was just a trial done where in Europe where they gave a randomized trial to get cream cheese at 3 different doses of note back bobble membrane that was enriched with these phospholipids and the highest note fat globule membrane cream cheese lowered blood cholesterol by 10 percent lower LDL by 10 percent so they were getting cream cheese and their cholesterol went down by 10 percent and it binds cholesterol and goes to the I am City Dairy that's not been ultra homogenized and not butter butters actually destroys macaws memorandum purpose so you can turn it into a block you know it might actually have cholesterol-lowering effect there's so many interesting pathways and and for 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 in weight when you think about health so lesson number three and I mention this term before is we have to focus on protective foods there's a there people say often if they have my toxin with this visit if I hear what you're saying it's 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 everything and anything you want and just kind of eat it in moderation whatever that means right it's a nutritional meal ISM right do whatever you want I'm saying there's good foods there's winners that we got to maximize and need much more of there's bad foods there's losers that we have to cut down on right there's not eat everything in moderation we have to eat much much more protective foods fruits nut fish vegetables plant oil whole grains beans and yogurt there's neutral foods um cheese maybe a little bit better than neutral unprocessed meats a little bit worse than neutral probably because the heme heme iron a lot of heme iron seems to increase risk of type 2 diabetes people with hemochromatosis get type 2 diabetes if you actually believe them they're type 2 diabetes improved women with gestational women who are at high 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 work tastes like meat they put heme iron into the burger right they put the one thing back that's probably put the harmful thing for you for 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 neutrals okay we can't always be eating the best possible thing on the planet like neutrals okay but we got to believe mostly eating the protected foods and they're 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 diets it's about 40% of calories right almost half of our calories are from refined starches and sugars and I really am emphasizing if you haven't heard me starches because it's a 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 that foods without sugars are fine and then processed meats are carcinogenic and also increased risk of stroke and other highly processed food and if you kind of put all these foods together I sort of you know looked at this a couple years ago and I said you know what 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 been run over right 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's you know the thousands of flavonols and phytochemicals and other bioactive compounds in those foods that nurture that new plant life that's what our bodies needs with with aging that's and we're just barely scratching the surface of the effects of flavonol 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 and many many other things we need to learn there's a lot of stuff not on this list garlic down on the list tumor it'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 phenolic and bio actives 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 a food processing right this you know so little about food processing additives emulsifiers and stabilizers and all of these compounds that 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 support it and then all kinds of diseases beyond cardiovascular disease allergies autoimmune conditions cancer brain oh there's so much we don't know yet about about food and nutrition and so you know take-home message again is it's about healthy foods and it's mostly about foods not a reduction in focus and this reduction is focused leads us in strange directions right low calorie less weight gain fat free healthy Latasha healthy vitamin fortified good for you which is not true right and these are all examples of weird products what is it fat-free salad dressing all right like how many people have ever had low-fat or fat-free solid dressing right like why would we do that like oil is good for us right soybean oil canola oil olive oil I put it in its really really good for us good for weight gain good for diabetes good for cardiovascular disease why would we ever eat low-fat saw what's in low fat salad dressing sorry nonfat soy dressing it's an oxymoron right what's in non-fat solid RISM start sugar and salt right and a bunch of chemicals and stabilizers right so definitely no any pet right is not good for you baked potato chips my other example right potato chips are not a health food I'm not saying they're health food but you're gonna eat potato chips they have three ingredients right canola oil or so even older avocado oil really really awesome and yummy you know 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 phenolic SIF it's a decent decent oil but for sure unsaturated fats it's actually good for you so if you're gonna eat the potato chip get the highest fat one you can dip it in oil either with avocados right lowers of ice to make index is better for you right so don't eat baked anything right eat high fat things that that are you know made with healthy oils and then assisted lesson number four that I want to get to in the last you know five minutes is that we've learned is that to really make behavior change it's not gonna be about education and telling people and dietary guidelines its systems changes right and this is a slide showing you know all of the influences on our 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 want it to create it foods that you know prevented hunger and gave vitamins of 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 in 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 buy 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 for changing the food system we have to do all of them right there's not going to be one thing this is a 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 interesting focus on the number one cause of world 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 healthcare we need to have nutrition in the electronic health record again the number one cause before health is not you know trying to CalPERS right we don't track it we don't measure it right that explains a lot healthy food prescriptions that people heard the guys in your health experiment where they gave fresh healthy produce to their poorly controlled type two 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 eight point one to six all right these will pay 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 snapped up by Google a few months after they published that and he's leading their entire new healthcare strategy now right they saw the dollars they were like - honey you save $200,000 in diabetes diabetes about one in four dollars and healthcare right this is a big issue so you 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 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 hi doing mr. Smith you were just admitted four months ago you're 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 the sickest patients in the healthcare system there's been many many studies now showing that if you give them meals at home about usually about 15 meals per week for them and their whole family healthy medically shared meals with it with the dietician you dramatically reduce healthcare utilization and so this is just one analysis that was publishers in about seven they use the Massachusetts all payers database and they match them you know incredibly well in a lot of ways they reduce hospital admissions by half they reduced nursing facility admissions by half net savings of 10,000 per patient per year after accounting for the cost of program number needed to treat right we love this in cardiology to patients with medically tailored meals to save one hospital admission one patient for medically tailored mule to save a nursing home admission it's unbelievable right and you know because of this there's strong interest in Congress and directing Medicaid to pay for medically tailored meals California is doing a six million dollar medically tailored meal pilot you guys should be doing this in hardcover 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 take just do pre post take your you know low income heart failure patients that are in and out of the hospital all the time and and hook up with one of these organizations I think manna is doing this mail so they can do mailed medic with Jeremy produce prescriptions this is the guys in your health experiment so I won't you know 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 and heart failure medically there's no that's been completed I haven't seen the results but I've heard through the grapevine that it would be exactly the same and a randomized trial about 50% or more reductions in hospitalizations this is a healthy produce 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 and all these outcomes we did an analysis of this what if every adult not sure really sick adults what if every adult in Medicare and Medicaid you know with their Medicare Medicaid card could go to the grocery store and get a 30 percent discount on fruits and vegetables right what if we gave this prescription to everybody how much would it cost how much help would it would it would it 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 your game and read 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 for quality adjusted life your 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 ten years the cost-effectiveness of this is thirty seven thousand dollars for quali 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 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 you know end with this you know 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 in is that was trying to innovate for health and sustainability craft x was bought by 3G 3G is this kind of ruthless cost-cutting Brazilian venture capital fund 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 is make your product of the cheapest cost and get them out and flash costs and we're gonna make money look what happened to their stock seventy percent decline in their stock they announced a fifteen billion dollar write-off earlier this year the biggest corporate write-off in history and then be on meat on the other end of the spectrum super innovative definitely good for the environment beyond me it doesn't have heme I don't know if it's good for better for you than need I suspect it's not but it certainly at least has that aura 33 million dollars of annual sales zero profits they have a market cap of six billion dollars right so these 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 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 that 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 the stuff we have a monthly newsletter that comes out it's online or print the tough health and nutrition letter very well respected written for the layperson covering all kinds of things that you know you want to know or the patients want to know or the protein bars work should I have supplements intermittent fasting you know coconut oil all the different questions people have and I recommend this for you know further reading so thank you very much and happy to answer any questions