How Diet Is Driving COVID-19 Outcomes

If you go into the grocery store, the supermarket, whatever, and you're thinking about what to buy, pick up even bread, modern packaged bread. If you pick it up and you can count five or more ingredients and you can't recognize some of them, they're.

Preservative additives, don't eat it. Welcome to the Doctor's Pharmacy. I'm Dr. Mark Hyman and it's Pharmacy with an F, a place for conversations that matter. And if you're wondering, how to prevent COVID-19 in yourself and in communities and why we're really seeing the staggering impact of COVID-19 on our economy, on our healthcare system, then this podcast is going to matter to you because it's with one of the leading thinkers in the space of chronic disease, obesity and health, Dr. Aseem Malhotra, who's a good friend of mine, coming to you from the United Kingdom, where he has recently published an article that caught my attention called COVID-19 and the Elephant in the Room. And we're going to talk about that elephant today, which is a perfect metaphor because elephants are big and the problem we have is big and it's because we're all big. Dr. Malhotra is an honorary consultant cardiologist at Lister Hospital in Stevenage, UK. He's a visiting professor of evidence-based medicine at the Bahiana School of Medicine and Public Health in Salvador, Brazil. He's a founding member action on sugar and was a lead campaigner highlighting the harm caused by excess sugar consumption in the United Kingdom, especially its role in type 2 diabetes and obesity. In 2015, he coordinated the Choosing Wisely campaign by the Academy of Royal Medical Royal Colleges as a lead author in the British Medical Journal or BMJ paper to highlight the risk of the overuse of medical treatments. He also became the youngest advisor in that same year to be appointed to the Board of Trustees of the UK Health Think Tank, the King's Fund that advises government on health policy. He's all over the media. He's published dozens and dozens of medical articles and journals like JAMA, Internal Medicine, Open Heart, British Medical Journal, and many more. So I'm so happy to have Dr.

Malhotra Aseem on my podcast today.

Welcome all the way from the UK. Mark, it's a pleasure to see you. It's great to see you too. So, are you staying safe over there in the UK?

Yes, staying safe luckily at the moment and more importantly trying to keep sane, I think like everybody. Are you on lockdown over there?

You're hiding out in your bedroom?

Yeah, completely on lockdown, completely on lockdown. Yes, it's all focusing on all the important stuff right now. You know, it's good food, sleep, getting.

Some exercise in there and trying to keep stress levels down. Yeah, well you've been also active in thinking about how we deal with this big issue of coronavirus and why we're really struggling because I don't think most people realize that the reason that we're sheltering in place, the reason we're in lockdown, the reason businesses are shut, the reason we can't go to sports games or university or schools, it's not actually because of coronavirus. It's because of us and how we're susceptible hosts to the virus. And if we were all super healthy, this would be a bad flu and we'd all be going about our business and we protect the very vulnerable and sick and old, but most of us would be okay. So the UK went into lockdown on March 23rd. There's been about 133,000 coronavirus cases and 18,000 deaths and it's changing every day. So by the time this podcast airs, it's going to be far more. And a lot of the focus is on ramping up testing and vaccine development and medical treatments But you're actually helping us focus on something different, what you call the elephant in the room, the link between obesity and the health outcomes from COVID-19. So here in the United States, it's 75% of us are overweight, and I think in the UK it's 63%. How are they related? How is obesity and COVID-19 related?

Yeah, Mark, I think you've definitely hit the nail on the head. The real pandemic is the pandemic of metabolic disease that we have in the UK and in the US. And just to give you some perspective, there's some very good data from the United States, which I referenced in my article in European Scientist, only one in eight adult Americans are metabolically healthy. I mean, that is extraordinary. Seven out of eight are not. And we'll define that shortly. But what that means is we are more susceptible, not just to all these diseases that have been putting so much stress on our healthcare systems, but what is particularly interesting or what we found from the data that we've analyzed and looked at with COVID-19 and what the CDC has been talking about is that if you have metabolic syndrome, if you have obesity, if you have type 2 diabetes, your risk of mortality is up to 10 times more than somebody that doesn't have it. Now, you mentioned earlier on that if we had a better healthcare system and we were a less stressed healthcare system and we were a healthier population, we may not have needed lockdown. And that's something I concluded with in the article. And I think you're absolutely right there, Mark. Just to give some perspective to the viewers and the listeners, on how lethal this virus is. So flu in itself, the overall mortality rate from the flu is about 0.1% or one in a thousand. The best estimates now suggest that for COVID-19, for coronavirus, it's probably somewhere between 0.5 and maybe 0.7%. So even seven times more deadly, if you like, than the flu. And certainly as it's a new virus, it's more contagious. You combine that with a healthcare system already, which is under stress because we haven't been dealing with the very diseases that you and I have been challenging and talking about for years, then it's a recipe for a public health crisis and that's what we've got. The reason why COVID-19 seems to be more lethal in people with metabolic disease and obesity appears to be linked to essentially excess body fat and chronic inflammation. So we have very good data from the flu from other respiratory viruses which are similar in many ways to coronavirus, which shows that people with obesity had higher mortality rates. So for example in 2009- so in.

Other words, if you're overweight, you're more likely to die from just a regular flu?

Yes, absolutely, absolutely. And data for example in California showed in 2009 with the, there was a flu pandemic then, and they found that 61% of people who died from that flu epidemic, that flu crisis then, had obesity. And the biological mechanism seems to be related to excess body fat and how that causes a dysregulated immune system, a dysregulated immune response to the virus, which then causes the cytokine storm that leads to ARDS or adult respiratory distress syndrome, which causes death. That seems to be the mechanism. Of course, there are other mechanisms as well. People who are obese have more restricted lung capacity. and this could also be a player factor. And of course, the people with underlying conditions are probably also more likely to suffer things like heart attacks. We talk about all these risk factors ultimately are big risk factors for heart disease. So you combine it all together, it's really the perfect storm. But the good news, Mark, and that's something I think we need to talk about is there are things you can do which can rapidly reduce one's risk and really reverse the metabolic syndrome. I think maybe it's a good opportunity for us to really talk about what those five metabolic markers are because it's not something that is part of conventional practice in medicine. You know that when you go to the doctor, they've got the standard, what's the blood pressure? Are you diabetic? What's your cholesterol? And then we treat those individual so-called risk factors with separate medications. The overlying theme is metabolic disease.

You're right, and I want to, before we get into the assessment of how we look at that and what we can do, I want to dig a little bit more into the data on how obesity is linked and overweight, not just obesity, and even what we call metabolically obese normal weight, which is, I refer to as skinny fat. You look thin on the outside, but you're fat on the inside. You're metabolically unhealthy. And that is up to 20 to 40% of thin people who are metabolically unhealthy. So when you think 75% overweight, And then 30 to 40% of the rest of the 25% of the people, the rest of the quarter population is not great. You're talking about like 90%-- Mark, you're right.

And I think that the most severe metabolic disease can affect absolutely 20 to 40% of people with normal BMI, but in a more sensitive way on sort of the latest definitions. And that again is a very interesting paper that shows, you know, looks at American data over several years. The most recent data shows that less than one in three people Less than one in three people with a normal body mass index between 18 and 25 are metabolically healthy. That means two-thirds of people of a normal weight are metabolically unhealthy, which basically means, as I've said before, there's no such thing as a healthy weight, only a healthy person.

Yeah.

Well, that's a good point.

So let's get back to how overweight and obesity affect your immune system. Because you mentioned that it increases inflammation in the cytokine storm. We know that's true because I've been saying you become pre-inflamed. if you're pre-inflamed, when the virus hits, it's like throwing gasoline on a fire. And when you look at the data, 94 to 97% of deaths are in people who are either overweight, obese, or have a chronic illness, which is related to being in poor metabolic health, diabetes, heart disease, and so forth. Even cancer is a sign of often poor metabolic health. So we know that these are all conditions that are resulting in pre-inflamed inflammation or inflammation. But there's some other interesting data that I didn't really realize about viral infections and obesity. For example, it suppresses white blood cell function. It actually increases viral shedding so that if you're overweight, you're more likely to spread the disease because your body keeps shedding and you shed more virus. And then you're, like you wrote in your article, your susceptibility to responding to vaccines is decreased. So when you get a vaccination, it may not work if you're overweight or obese and we're depending on this vaccination to save us. But what you said is that 90% of the population essentially is metabolically unhealthy and the vaccines aren't gonna work as well.

Is that true? Yeah, that's true, Mark. Certainly with the flu, we've seen that. That's the case. And I think that's a really important message also moving forward because that's what's happening at the moment. A lot of resources are being directed to waiting for the vaccine. But actually, even for the vaccines to work, you need to maximize your chances by improving your metabolic health. And in terms of the viral shedding, yes, certainly with the flu, it appears that if you're obese, you have the virus on average 42% longer than people who are not obese. And it's an observation. Of course, you know, anecdote isn't the highest quality of evidence, but it's an interesting observation with what we know. Over here in this country, several members of our government ministers cabinet, if you like, including the prime minister, got afflicted with coronavirus. The chief medical officer, the chief executive of the NHS, the secretary for health, and Boris Johnson, the prime minister. Now, Boris Johnson got the sickest. He got admitted to hospital. And he's overweight. In fact, I would say he's probably obese. I worked for several years as an advisor to the London Food Board when Boris Johnson was mayor of London. And I won't name this person, but someone very senior said to me, you know, even the fact that Boris used to cycle a lot, when you see Boris on TV, he's pushing the fitness thing, and he's cycling everywhere, but he's considerably overweight. And this individual said to me, you're a doctor, I'm very concerned about Boris. He doesn't look well. He is obese. And I think that also brings us onto the discussion briefly. I think that there is still a bit of a misperception or misunderstanding there that you can be fat and fit. Sorry, you can't. The data shows that even if you exercise, if you've got excess body fat, you are at higher risk. And I think that message also needs to get out to the public because there still seems to be a lot of misinformation that, you know, you can outrun a bad diet. And as long as you're working out, I'm sure you see it in America's probably lots of people who are overweight or obese who are exercising now. We're not saying don't exercise. Of course it's a good thing to do for you. actually, you'd be doing a lot better if you also changed your diet and got your weight down.

Yeah, I mean, I always say you can't exercise your way out of a bad diet. That is far more an impact. And yes, if you clean up your diet and you exercise, that's ideal. And I do both. But if you see so many people who are very overweight, who exercise a lot, it's because their diet is not right. So, that's the key. And what's interesting, it's not just any fat, it's a certain type of fat. and a certain location of fat. So can you talk about this uniqueness of this type of belly fat that's causing the problem?

Yeah, it's a visceral fat, isn't it? It's a fat that really surrounds the vital organs, the liver, the pancreas. That is what causes the also the dysfunction, if you like, of those organs that link to dysregulated metabolic control of glucose, insulin resistance, and over time, this is what causes all these, always at the root of all these chronic diseases, heart disease, high blood pressure, type 2 diabetes, probably also cancer and Alzheimer's disease as well.

Yeah.

So that's really the root of the problem. I mean, just a slightly interesting anecdote, Mark, for you. You know, I like to follow my own advice for many years. We've discussed this before, you know, this isn't about being preachy. You know, we have been through situations in life where Before we became better informed, we had our own issues with adverse health because of that diet. I was still very active, but I was getting through 40 teaspoons of sugar a day. This is what I did for many years until I read the science. And I thought, what the hell am I doing to myself? You're a cardiologist, so it's the fat, right?

I was a trainee doctor.

I wasn't a specialist in cardiology at that point, but once I looked at the science, I had this belly fat. I wasn't particularly overweight, but I had this belly fat. And as soon as I cut sugar from my diet, I lost about a.

Stone all around my belly. Okay, where's the stone?

Because most Americans don't know what a stone is. A stone is probably, it's about 6 kilos, it's about 12 pounds, 12 to 15 pounds, something like that. 17 pounds. Oh, really? It's okay, fine. So yeah, it's quite a lot, quite a lot of weight. And it was all around my belly. And the reason I'm telling you this is obviously, you know, I've been trying to walk the talk, following my own advice for several years now. And just before the lockdown happened, they have this very interesting exhibition in London, which is probably, I think it's around the world because my relatives in San Francisco have seen it as well. Body Worlds. Have you heard of Body Worlds exhibition? So basically they take cadavers, human cadavers that are preserved, and they educate the public and you can see organs and the body and it's fascinating. It's really interesting, very educational, even for a doctor. But in this exhibition, they also have one of the highest type of body scans that look at your muscle mass, your body fat percentage, bone mass, all that kind of stuff. And I didn't know this, but it gives you a metabolic age at the end of it all. So I thought, okay, I'm going to get this done. Let's just see what it is. I'm 42. I'm not afraid to admit that I'm 42 years old. My metabolic age on this scan came back at 29. So I'm pretty happy about that. I'm apparently 13 years younger in terms of physically than my true age. I think maybe that should be an incentive for people.

That's right. Well, I got my telomeres going. I'm 39, I'm 60 years old, but I'm 39 on my telomere.

Yeah, exactly.

It's great. So getting back to this belly fat, because it's not just there holding up your pants, this inert blob of fats around your belly, it's an alive organ. And this is really what's driving the crisis of COVID-19. because this organ is producing what we call inflammatory cytokines. These are the messenger molecules of your immune system, and you basically have a belly on fire. And it also produces all sorts of hormones and appetite dysregulating signals and all kinds of things that make you hungry and gain weight. It's really bad news. So it's not just the average kind of fat. So what are the ways in which you mentioned 12% of Americans are metabolically healthy? That's pretty shameful. What are the types of things you would measure to look to see if you're metabolically healthy or not? Fair enough. So really, really good question. If they're at risk for COVID-19 because they're metabolically unhealthy, how would they know?

Yeah, absolutely. Very good question. And before I answer that, I think the other thing also, just from a personal perspective of my interest as a cardiologist, and this is something that I wrote about in the BMJ many years ago, that our focus should be metabolic syndrome, the three of the five that we're going to talk about, is that two-thirds of people who suffer heart attacks, have metabolic syndrome. Most of them will have a normal cholesterol. So this is really the other elephant in the room is this is what we should be focusing on if we're going to reduce heart disease as well, as well as improve people's health.

Yeah, people like about blood pressure and cholesterol. People don't realize that most heart attacks are caused by sugar, not fat, and starch.

Absolutely, absolutely, absolutely, Mark. Absolutely. And now we're trying to wind back these harms of years of people getting the wrong dietary advice. To answer those specific question about what are the five factors? So the normal blood pressure means less than 120 millimeters systolic of mercury and less than 80 diastolic. Waist circumference for a man of less than 102 centimeters and for a woman less than 88 centimeters.

What's that in inches?

In inches is, I think that's 40 inches for a man. and 35 inches for a woman. You have to just check that, but it's- I think that might be a bit- 2.5 inches, so maybe it's a bit less, sorry, 2.5 inches to a set.

I think it's 37 for a man and like 34 for a woman or something, maybe?

Yeah, yeah, I think we'll have to- yeah, yeah. So just convert those centimeters to inches if you've got a calculator there, and whoever's listening and watching. And then in terms of the- you might have to help me with the units for triglycerides over here. We say triglycerides greater than 1.7 millimoles per liter and HDL cholesterol should be greater than one millimole. So triglycerides should be less than 1.7 and HDL should be greater than one millimole, I think.

I mean here they talk about triglycerides less than 150, although I think ideal is less than 70. And HDL, you know, over under 50 if you're a woman, I think under 40 if you're a man. But again, those are not optimal numbers. Those are, Sure.

Just for this specific definition of metabolic health, I agree, absolutely. And then finally, last but not least, is your HbA1c. You want to be not pre-diabetic, so less than 5.7%. You want your hemoglobin HbA1c again, I think you use millimoles over there in the United States.

That's the average blood sugar over the last six weeks, basically. It should be less than 5.7, but again, ideal is probably less than five and a half.

Yeah, absolutely. So if you're in all of those parameters and you're metabolically healthy, and of course, if you have one, then you then come out of the optimal metabolic health. If you have any three abnormalities of those five, you've got metabolic syndrome and that is associated with the worst outcomes in terms of all sorts of health problems, but also with COVID-19.

And I think also they talk about a blood sugar over 100 in this country. And the other thing that people don't measure, which I've been measuring for 25 years and is probably the most important measure, is fasting insulin, which is something that nobody looks at, which is very strange because your insulin goes way up before your blood sugar goes up. So getting your insulin measured is one of the most important things you can do. And if it's normal, you may not be out of the woods, even if your sugar is normal, because the best test is actually a glucose tolerance test where you take a load of sugar, the equivalent of two Coca-Colas and you see what happens over one and two hours in fasting. And that will tell you, and I've seen this one woman in my practice just stuck out like a sore thumb. She was very overweight. She had that big round apple belly. and she had normal blood pressure, her cholesterol was normal, and her blood sugar was normal. So I'm like, what is going on here? So I did a glucose tolerance test. Her blood sugar fasting was under 100. It never went over 110 after the glucose tolerance test, which is normal, which is great. Her insulin fasting was like 30 or 40. It should be less than five. Ideally it's two. and at one in two hours, it was over 200. Wow.

There's a ticking bomb, basically. She was wearing out her insulin.

Yeah. And so it taught me a lesson that you can't just rely on blood sugar or even fasting insulin or any of these other biomarkers that they're all surrogates for the hyperinsulinemia or insulin resistance.

That we're seeing with these patients.

Absolutely. Absolutely. So let's talk more about this other parameter that we look at called Metabolically Obese Normal Weight. And what is it? And you talk about something called sarcopenic obesity. So what are the dangers of not picking this up, particularly in the elderly who have a normal weight, but are also really metabolically unhealthy? Because we see a lot of the elderly having risks. And it's not because they're old, it's because they're metabolically unhealthy. because of what you call sarcopenia. Yeah.

So essentially, as you get older, Mark, suddenly after 50 into your 60s, people tend to lose as part of the aging process. Muscle mass does tend to decline. You can't stop it, but you can slow it down. I'm reversing it.

I'm working out now. I'm at home with COVID-19, and it's the first time I'm not on the road in 25 years, and I'm doing weights at least three times a week.

And I can see massive improvements in my muscles. Yeah, you're in great shape, Mark. You're a great role model actually for.

That, you know, although I know you're 39.

Mark's like, what's going on with your shoulders? No, but I mean, that's a really good point. And of course, and what's really important as well is to get enough protein because there is a big issue, certainly in the Western world as well, protein deficiency. A lot of older adults aren't eating enough protein. Of course, you know, the best sources come from animal products, but you can obviously get it, you know, slightly harder from vegetable products as well, and pulses and things like that. But you need to be eating a lot of protein. And of course, combining it, you're right. with some strength and resistance training, it's really important for older people. And that will then reduce the chances and probably stop sarcopenic obesity happening, where essentially what happens is you lose some muscle mass and you gain excess body fat, certainly around the midriff, which is again part of the aging process seems to be that people do develop more insulin resistance with time. So actually as you get older, I think it's more important to be actually more strict about what you're eating and thinking about it. And again, it's never too late to change, as you've probably seen with your patients, as I've seen with my patients, even as they're older in their 60s, their 70s, even 80-year-olds, even from changing their diet dramatically and just making some changes to their exercise levels, they can improve their health markers and also, for them, their sense of well-being, they just.

Feel mentally and physically better. Yeah, and I think the way we think about aging is just all wrong. It's really we should be calling it inflammaging. which is an inflammatory condition driven by our diet and our lack of exercise and lifestyle choices, which are something that we have control over. And I've seen patients at any age, whether they're 60, 70, 80, get better as they get older. And I see this with myself. My numbers are all better. My fitness is better. My strength is better. My muscle mass is bigger. I'm not saying that to brag. I'm just saying that, you know, I was so busy changing the world for the last 20 years that I kind of neglected Some things I ate pretty well, but I didn't do the kind of exercise that I really wanted to do and needed to do. And I wasn't as diligent about sleep or meditation. And now I'm really good. And I just noticed that I am actually healthier at 60 than I was at 50. So, I think, you know, there is a point at which that might not be true when I'm 90 or 100, but I think it's more true than we think. And I think the reason we're seeing people in the hospital dying is either because they're overweight or obese or because they're older and they're very connected. It's not like they're two separate problems. So, yeah, and I just talked to a friend who's a ICU nurse and said, they said there isn't anybody and this may just be the one hospital. I don't know how universally true this is, but there isn't anybody in the ICU under 250 pounds.

Wow.

Which is an incredible observation. Now that may not be true in all hospitals, but that caught my attention. It's like, wow.

Yeah, I think, Mark, as well, what we should also just briefly mention as well, there seems to be a disproportionate effect for people who come from we describe here as BAME backgrounds, so black and ethnic minority backgrounds. I know that there's some similar statistics over in the United States. Some of it may be related to social inequalities, but it seems certainly from from South Asian origin, India, Pakistan, for example, Bangladesh. There is a much higher proportion amongst NHS staff of those people dying. In fact, 70% of the people who have died, who are National Health Service workers, are from BAME backgrounds. And only 14% of the population are from BAME backgrounds. So it's hugely disproportionate. And the likelihood is, what does that mean? Ethnic minority. So from Indians or South Asian origin. And it's probably because metabolic syndrome or metabolic diseases have a much higher prevalence in these communities, not because of genetics. It's a complex different factors, but it's mainly lifestyle. And even we talk about social inequalities and you'll hear a lot of that discussion, the question is on a biological level, it's still metabolic syndrome. And there are obviously lots of factors playing into it. But as you know, Mark, people in America who come from the poorer backgrounds also tend to have worse diets. They tend to, you know, and for lots of different reasons, they may be struggling to make two ends meet, and they will go for the cheapest available food and often that's high sugary, starchy, ultra processed junk. So this is probably the big factor that's driving this. And I'm sure we're obviously going to talk about food shortly, but this is, you know, this is another big problem that we need to think about. I think you're right.

I mean, I think, you know, there are certain populations genetically that are susceptible, you know, Native Americans, Pacific Islanders, Asians, Indians from India and Pakistan and so forth, and of course African Americans, they're all more susceptible. But that doesn't mean that they're predestined, they're just predisposed.

And when they put it in a.

Food environment that is harmful to them, which is our current food environment in the world, that's what triggers it. And it's pretty shocking. In Chicago and Louisiana, where they have good data, 30% of the population is African-American and 70% of the deaths are in African-Americans. And there are white counties and black counties are compared and black counties have six-fold higher risk of death. Now, people say, well, you know, it's their poor diet, they should take care of themselves, they don't pay attention. But you've written a lot about how this whole idea of blaming the victim, personal responsibility is fundamentally flawed. Can you really talk about why we shouldn't be blaming the people who are eating the bad food?

Yeah, Mark, I think, yeah. So personal responsibility, I think we have to define it first. To exercise personal responsibility, two basic things you need is knowledge, you need the right information, and you need choice. You need to have access, it needs to be affordable, it needs to have access. Ultimately, because the food environment is really what drives our behavior more than anything else in terms of what we eat, and ultra-processed foods have become unavoidable, it's very difficult. It's much more difficult to exercise personal responsibility. And one great example of this, Mark, and something I've campaigned heavily on in the UK, and there's still a controversy going on over here at the moment, is around junk food in hospitals. So in the UK, the most recent--.

We shouldn't have McDonald's and Krispy Kreme.

And Domino's Pizza in a hospital. It's really quite shocking, Mark, isn't it though? I mean, we're supposed to be promoting good health and be temples of health. Yet we are selling the very foods and promoting the very foods in our own hospital environments that are responsible for the chronic diseases driving the people into the hospital in the first place. I mean, you really couldn't make it up. In the UK, 75% of food purchased is unhealthy. And more than 50% of National Health Service employees, doctors and nurses, are overweight or obese, which is a clear example that education is ineffective when the food environment is working against you.

Having all that food in the hospital is good for business, right? You just keep the patients and their family.

It sounds that way, but I don't think that's the real reason. I think they do get money from, in the short term, but they're not thinking outside the box.

They have contracts. At Cleveland Clinic, the CEO, when he was hired, the last CEO, he decided to get McDonald's out of the hospital. And he was just skewered by the media because it was owned by an African-American and they were like, how can you do that? It's racist. And he got so in trouble and he had to wait till a contract which was a 20-year contract. And it was interesting, the day the contract expired, they brought a crew in, worked overnight, and literally shut the whole thing off. And then they had a new restaurant in there very quickly. He got rid of all those sugar sweetened beverages, all the junk food gone from the hospital.

Amazing.

It still needs a lot of work, but... It does.

And I think, Mark, the point as well is, you know, is if you do change the food environment, it has an impact. Alissa Epel from the University of California, San Francisco did a study in one of their hospitals where they removed, just removed all sugary sodas basically. And then they repeated and they took a sample of people that worked at the hospital and then they looked at their markers of metabolic disease one year later and there were significant improvements in things like fasting insulin, waste accumulation went down. This stuff works, it happens. And this is just by getting out of the, we're not saying people can't have these as treats if they really want it, they can buy them, but we They shouldn't be literally, they become unavoidable. And it basically also means that you displace healthier foods. It's going to be good for you, right? So I think it's a no-brainer. And if people want to argue that choice, you should ask them also, do they also think that we should bring back smoking in public places? Should we be smoking in hospitals? One cigarette won't kill you, neither will one donor. But over time, they cause significant damage to health. And right now, the big issue of our time You know, what's responsible for more disease and death globally than physical inactivity, smoking and alcohol combined is poor diet. And ultra-processed foods really are the low-hanging fruit that we need to concentrate on. More than 50% of what we consume in the UK, and I'm sure that it's similar in the US, is ultra-processed junk food, Mark.

60% of our calories is junk. Yeah, it's not a competition we want to win, but it's 60%. Yeah, it's pretty terrible. You know, and I think what's striking looking at the data is that over 70% of deaths worldwide are not from infectious disease. They're not from malaria, RTB or AIDS or viral pandemics. They're from lifestyle preventable, mostly diet preventable chronic disease. Something people don't realize. And yet most of our resources are focused on infectious pandemics, malaria, TB, AIDS, viral things. I mean, these are good things to support and deal with, but when you look at the Gates Foundation, they're the most influential foundation in health out there, and they're not paying much attention to this. They're starting to, but this has not been a focus. And I think this has just come on like a juggernaut over the last 40 years, and people just haven't been aware that this is happening. And now COVID-19 is what we call an acute on chronic problem in medicine. Yes. Someone is basically healthy, they'll get sick, it may not be too bad, they'll be fine. But if someone's metabolically unhealthy like your prime minister, it's gonna hit them hard. And they're already a sitting duck and that's what we call acute on chronic. If someone has emphysema and they get pneumonia, they're in trouble. If an average person gets pneumonia, they'll sort of have a few uncomfortable weeks and they'll be fine. But this is really where we need.

To address this problem globally. Mark, actually on that note, you know, you start at the beginning talking about the focus being all about vaccines and treatments and all of that stuff. And I think that leads into another area of discussion, which is there is a cultural problem, a misperception about what modern medicine can achieve. We know, for example, you and I know that the effects of all these drugs that people take for type 2 diabetes and blood pressure and cholesterol are very marginal at best. But there was a very interesting study which I-- They're not just off for.

Effectiveness, but they create great profit margins for the pharmaceuticals.

Huge, huge. But there's a very interesting paper I found which looked at, and took educated people in the United States and asked them, since the mid 1800s in the United States to now, there's been an average increase in life expectancy of 40 years. And they asked these people in this survey, a lot of them, some of them were public health students, how much of that do you think was because of modern medicine? 80% of the people replied, most of them thought it was 32 years. 32 out of 40 years increase in life expectancy in the United States since the mid 1800s was because of modern medicine. Nothing could be further from the truth. At best, three and a half years you can attribute to modern medicine. Three and a half years at 40 years. And most of that mark is because of acute care, vaccinations, certain, you know, that's antibiotics for infection. These are the things, the big kind of things that have helped modern medicine more than anything else. Most of the other stuff has been public health interventions, you know, safe drinking water, seatbelts in cars, smoke-free buildings, better working environments, safe working environments. This is what has contributed most to people's longevity. So there's a perception issue that we need to challenge because this sort of stuff also influences how people behave, what politicians do, what policies we have, where the money gets distributed. It needs to go all the way into prevention now. And everyone needs to be educated this. all the way to the highest level, politicians, you know, these are the kind of people that need to really understand this stuff, and then we can change the system.

You know, I agree. I think we need sweeping policy changes, and I've written in my book about this food fix, which you're featured in, and I began to understand why we have this situation we have. You know, it became very clear this is not an accident. It's not just, you know, a bunch of bad decisions that happened and that are going on with nobody really sort of being accountable. You know, there may have been early on a desire to feed a growing world and a hungry population by using industrial agriculture to produce an abundance of cheap, starchy calories, which we thought at the time was a good thing. But now we understand the consequences of that. And when you look at the way in which the food industry acts for the most part, it's a deliberate way to subvert the truth and promote their products. One, they fund billions of dollars of research, quote, research that candy, for example, is a healthy way for kids to lose weight. No kidding. That's an actual study. They fund $12 billion compared to $1 billion from the National Institute of Health, which confuses the science and confuses the public. They co-op professional associations, and you've talked about this, like the American Heart Association, American Diabetes Association, Academy of Nutrition and Dietetics, where they fund their their work, which is why, for example, the American Academy of Nutrition and Dietetics, they actually created a sponsorship for Kraft Singles as a healthy snack. Well, they can't even call it cheese because it's not 51% cheese, and they got called out for that and had to pull it out. Then they co-opt social groups like Feeding America and the Food Policy and other groups that are trying to do good work around hunger, but they sit on their boards, they fund them, they fund groups like the NNACCP, which is the African American group or Hispanic Federation, which is why they oppose soda taxes. They create friend groups that create propaganda like the American Council on Science and Health that says that pesticides, trans fats, smoking are not bad for you. And so are GMOs great. They're funded by the usual cast of characters like Monsanto and and the big food companies. So it's a deliberate attempt across a wide range of sectors of society and science and government, not to mention the amount of lobbying they do in Washington. So you've got all these factors that are impeding our ability to create proper information, proper access to the right food, and to actually support the growing of the right food. So we're in this sort of real crisis at this moment where even if we want to, It's not easy for people to do the right thing.

Yeah, Marc, I couldn't agree more. I think, you know, I would sum that all up as that we have the corporate capture of public health, essentially. You know, Marci Angell, who I interviewed for an article in the Guardian, the former editor-in-chief of the New England Journal of Medicine, said the real battle we have in healthcare is one of truth versus money. But, you know, if you ask the public, I believe in democracy, Marc. This is about, you know, informed decision making. And if people were aware of it, if people were really what is a gross injustice being committed on them, they would find it unacceptable. Doesn't matter what your political, you know.

And everybody should read my book, Food Fix, because that's what I talk about. Have you got a copy? Exactly.

I gotta get you a copy. I look forward to reading it. So yeah, this is really what we need to, you know, get that information out there, make people aware, and then we can change the system. Because ultimately, you know, what I think the COVID-19 also outbreak has highlighted is that we're all interconnected, you know, and this sort of, you know, nothing, this is really unprecedented, this whole lockdown situation. Where people are really, seriously, everybody is so worried about their future, what's going to happen next, you know, if a deadly virus was to come along, would we as a society, as a population, would the world survive it? And I think this is hopefully a wake-up call for people to realize actually we have to all, you know, we have to, to look after ourselves, Mark, we have to look after other people too. You know, even if from a purely selfish perspective, we have to, we're all interconnected and that means thinking about all these social inequalities. You know, the people that-- you know, there was a very good point made by one economist, I think it was Nam Chamski, but basically saying that.

You.

Know, we can survive-- the world can survive without a few billionaires, but they can't survive without the people that, you know, take the public train, that look after public transport, that look after the garbage, you know, healthcare staff, It's pretty.

Bad if the garbage collectors didn't come.

We're all dependent on them, so we have to really help each other as well through this.

I agree. I think it's really an interesting moment in history where we're going to have an opportunity to sort of uplevel our humanity and our mutual interdependence and sort of reshape the way we've been going, which is in a sort of a narcissistic, individualistic, sort of totalitarian pathway that I think has sort of got to stop.

Yeah, and it's not bringing us great happiness mark either. You know, there's increasing depression as well because of the way we live. Yeah. You know, so, you know, I think we just need more compassion to help ourselves. Compassion for others to help ourselves.

Absolutely. All right. I want to come back to this question of what the heck is ultra processed food? You've used that term a number of times. I don't know if people know what it is. What is ultra-processed food?

Let's define it. It comes from something called the NOVA classification, which came from Brazil. It's an internationally recognized classification of different types of foods from minimally processed to ultra-processed. Group 4 is the ultra-processed, the worst type of foods that is really linked to chronic metabolic disease, heart disease, cancer, obesity, type 2 diabetes. Before I define it, what's really interesting about it, it appears these sorts of foods also encourage overconsumption. Kevin Hall, a scientist in the States last year did a very interesting, what was described as a land randomized control trial. They're just within two weeks of people eating ultra processed versus minimally processed foods, there was a two kilogram difference. So they were just encouraged to eat till fullness and people who had the ultra processed food end up consuming more and end up gaining more weight. What is ultra processed food? Overall general term is usually mass packaged food that is deficient of nutrients and fiber and is high in sugar, in starch, in unhealthy oils, additives and preservatives and mostly, you know, most of the time quite often it's five or more ingredients. So what I tell my patients in a very simple terms, so it's not a whole food. It's just out of a packet and it has five or more ingredients. It's ultra processed, don't eat it. Very simple, very simple. So if you go into the grocery store, the supermarket, whatever, and you're thinking about what to buy, pick up even bread, modern packaged bread. If you pick it up and you can count five or more ingredients and.

You can't recognize some of them, they're preservatives or additives, don't eat it. I've been making Indian food at home.

Using all the spices. I might use 20 different ingredients in my Indian cooking.

I think that's different though, isn't it? Because you're using all natural ingredients to cook at home. This is specifically packaged food with preservatives in it. I'm making my own. Tikka Masala and Josh and it's so fun. I'm not even buying the mixes because I have time. I'm using all these incredible spices, toasting them. It's so much better. Yeah, I agree. So yeah, ultra-processed food is bad. It's also, it's both the abundance of ultra-processed foods, which are nutrient-poor, mostly starchy and sugary, but also the absence of protective foods. So, can you talk a little bit about what that is?

Yeah, absolutely. So, you know, this is something I've seen, I wrote a book about, but looking at all the evidence, so we talk about chronic inflammation. So, the way I look at it is two things going on. How do you combat chronic inflammation from food? And how do you reduce the risk of you getting insulin resistance? So, you know, those are sort of the twins, the terrible twins, you know, they're really going to be damaging to your body. So anti-inflammatory foods, I think about that, I think about good nutrition. So in particular, what I recommend people to have is something which is a low refined carbohydrate, Mediterranean inspired diet. So that means lots of whole vegetables, ideally low sugar fruits, nuts and seeds, meat that's grass fed, oily fish, eggs, full-fat dairy, and one that is devoid or certainly less of the starch and sugary stuff, so bread, pasta, rice, and potatoes. Now, if you're metabolically healthy, you can get away with more of that. If you're working out and doing a lot of resistance training, then you can have more of those foods. But the real issue in America and many of these Western countries is that we're consuming too many low-quality carbohydrates, which come from ultra-processed foods. The statistics in the US from the most recent data suggest 42% of all the calories being consumed in the United States comes from low quality carbohydrates. In particular, carbohydrates are basically refined, sugary carbohydrates and flour.

Flour.

Carbohydrates are like fiber, basically.

Yeah, flour and sugar, which is basically what we eat in America.

Yeah, yeah, exactly. So I think if people get that right, You know, even if 80% of the time, Mark, you know, I would say, it depends where you're at. If you're overweight or obese, you've got type 2 diabetes, go cold turkey, go extreme, you know, for the first month or two. I mean, you may have a different approach. And then, you know, things when things settle down, doesn't mean you can't ever have a pizza ever again. But really, what I would say is that 80% of the time, and people get conditioned that they're able to do it, you practice this 80% of the.

Time, and the other 20% have your treats. I'm a little tougher than you. I'm like a 90-10 guy. I'm like a... Here's the thing. It's so dependent on your metabolic health, right? So my goal as a functional medicine doctor is to make my patients more metabolically resilient, right? If you have diabetes, you are not metabolically resilient and you don't have many degrees of freedom in that. But if you, like you said, if you're doing exercise and you're eating healthy most of the time and you want to have a little pasta or a piece of bread, it's not going to kill you and you'll be fine. You'll be able to handle it. But if you look at my patients who have severe metabolic disease and diabetes, they need aggressive treatment. And some of our colleagues and friends are using ketogenic diets which basically eliminate all the carbohydrates from the diet, which is 5% carbohydrates.

It's very, very low.

And they're seeing reversal of diabetes, type Yes. Diabetes, which is not something we learned about in medical school. You can't reverse type 2 diabetes, but it actually can be reversed, but it requires an extraordinary and often heroic change in diet, which is not easy for people, but if you've spent your life getting there in decades and decades of ruining your metabolism, it actually doesn't take that long. Within six months to a year, you're going to be really good if you do that. Yeah. Even within some of my patients, Mark.

I'm sure you've seen it as well, even within a few weeks, I've seen people send their type 2 diabetes into remission in 28 days.

Oh, yeah.

I think that's a really important message with COVID is that if people do these changes now, they are going to be metabolically more resilient, their immune system is going to be more resilient within the space of a month.

Or less. I mean, I had a patient who I talked about in the book, Janice, who was diabetic, her BMI was 43, which was very, very overweight. she was on insulin. And within three days of changing her diet, she was off insulin. Within three months, she reversed her heart failure, her diabetes, her kidney failure, got off all her drugs. I see this very often. And when you look at people who are getting bariatric surgery, gastric bypass surgery, within literally days to a week or so, if they're diabetic, their blood sugars are normal. And they're still very overweight, which is.

Fascinating to me because it means that it's not the fat, the food. Yeah, not the fat, it's the food.

And if you focus on that...

There are benefits independent of the weight loss, absolutely right, Mark. Yeah, for sure.

The food is that powerful and we always talk about how food is medicine, so that's great. Now, the problem for people and everybody's at home and trying to figure out what to eat and cooking is that, you know, there are a frame we often hear, it's expensive, it's difficult, it takes too much time. Well, we have more time now, so... But the cost factor of eating Whole Foods is a big hurdle for people. Can you talk about that? Is it true? Is it a myth? And why are we buying into that?

Yeah, I think to some degree, it's more difficult to... I mean, the junk food tends to be a lot cheaper, that's for sure. But you can, if you try on a budget, eat healthier foods. So for example, an apple costs less than a candy bar. certainly in the UK. But it is more difficult because a lot of these sorts of junk foods are very heavily promoted and marketed and more unavoidable and highly addictive. So I think that it is possible but it's hard. And that's why I think again government needs to act. So we you know we had over here we've introduced you know a soda tax and it's definitely reduced consumption of sodas of sugary drinks. We know that the most important factor which resulted in the decline of cigarette consumption in the United States and other countries was the taxation of cigarettes specifically, so increasing the price. That's what needs to be done, is that these sorts of foods need to be made more expensive, and then simultaneously you need to make healthier foods more affordable. And if you do it on a population level, then we'd see much-- we'd see differences very quickly. I mean, Darius Mozaffarian and Simon Capwell who's a professor of public health here in the UK and Darius obviously is over there in the US. He's a big nutrition scientist. It's done a lot of research on dietary, you know, population and public policy on diet for years.

Yeah, in fact, we just, you know, recently published an article in the Boston Globe about how COVID-19 is a diet-related illness and how millions will die unnecessarily.

Absolutely, absolutely. You know, he pointed out that, you know, 11 million deaths diets a year are attributed just to poor diet. But actually, with policy changes that just included slight improvements in people having more vegetables, more omega-3s, cutting out the sodas, within a year, say, if that happened globally, his estimates is that you could half, literally half, the deaths from heart disease, from 10 million to 5 million, just within one year of people eating more whole fruit and vegetables, and oily fish, and nuts, and seeds, and cutting out the junk. So that's pretty extraordinary. Now, of course, some of this data is not, can be questioned in terms of how reliable it is because we haven't got randomized controlled trials. But it's still in the ballpark, I'm sure. I have no doubt that across the world, if people change their diet even slightly on a healthier side, then globally we would be in a much better place.

I think there is a myth about the expensive nature of good food. I've had personal experience with this. The data is really clear that it may be 50 cents or more a day to eat well, but maybe not. And that it may be equivalent if you pick foods smartly. Beans and whole grains are cheap foods. A lot of vegetables can be cheap foods. Cabbage isn't very expensive. There's a guide called Good Food and a Tight Budget from the Environmental Working Group, which I'm on the board of, which It explains how to eat well for less. Good for you, good for your wallet, good for the planet. And, I did this with a family of five living in a trailer in South Carolina who was very overweight and sick and diabetic on kidney dialysis at 42. One of the father was terrible from diabetes. And, they actually lived in one of the worst food deserts in America. And, I showed them how to cook a simple meal from scratch. and I gave them this guide on how to eat well for less and a cookbook. And I said, you can do this. And I was like, I don't know if they're gonna do it. Can they do it? Together, they lost 200 pounds in the year. The father lost enough weight so he could get a new kidney. The son lost 50, but gained it back because he went to work at Bojangles, which is a fast food restaurant. And then he eventually got sorted out and he lost 138 pounds and asked me to write a letter of recommendation for medical school. And they didn't have a lot of money and they didn't know how to, they didn't know how to cook. They didn't know what to shop. They didn't have the skills. They didn't have information. They didn't have the knowledge. And I think that is really the problem. It's not, it's not a lack of money. It's a lack of awareness, education and skill. It is really something that can be addressed effectively. And the other problem is that the real cost of our food is not the price we pay at the checkout counter. So what is the cost of Twinkie when you buy it? Very little. What is the cost to human health? What is the cost to the environment by how we grow the food using industrial methods? What is the cost of the effect on our healthcare system, on our federal tax collections that we have to spend the most of it on healthcare? I mean, there's so many costs that are not in the price that if we actually paid the real price, maybe a Twinkie would be $20 and a grass-fed steak vegetables would be like $5, right?

Yeah, sure.

Very different.

Absolutely, Mark. And also, I think the cost down the line, isn't it, to your health? I think people also need to think that, you know, even if they end up spending a little bit more now, they're going to be saving money later.

So how is this effort going in the UK? You're probably the most vocal advocate of dietary change in the link between our diet and chronic disease and the burden on our healthcare system in the UK. How's it going over there? Are you getting traction? Are people listening? Yeah, Mark, I think there is traction.

Certainly with the low-carb movement in terms of types of diabetes. It seems to be improving, but I think there's still a big cultural problem amongst the medical profession. And the reason I say that is even today there was a news story based upon a tweet that I did yesterday. And the tweet was my response to the fact that one of the hospital trusts in the UK had endorsed and pushed out and congratulated Krispy Kreme donuts for donating for free 1,500 donuts to one hospital for the staff. 1,500 donuts. And there was a big issue around it. So I tweeted, I said, this is disgraceful that in the middle of an obesity epidemic, when the staff were overweight or obese, this is why you're endorsing this stuff. And it wasn't just me speaking out from a personal perspective. I've campaigned to make sure that policies change where the British Medical Association many years ago actually passed a motion to make it part of their policy through a cause I had made that we should ban the sale of junk food in hospitals. So it's a marketing opportunity for these companies, as you know. Big Tobacco did the same thing. They used to use doctors to advertise cigarettes in the 50s. You know, this is something...

I actually, as you know, I have in my office an original ad that I got on eBay. of Camel cigarette ad, which said 113,000 doctors from coast to coast recommend Camel cigarettes more than any other cigarette. And it shows a doctor smoking at his desk with a white coat on. And I have it framed in my office. Wow. That's extraordinary.

It is extraordinary, isn't it, when you think about it. And the parallels are quite, you know, they're very chilling. They're similar parallels with what the food industry do, because for them, it's a marketing opportunity. It's a branding opportunity. Everybody's looking at the health heroes right now in the National Health Service and clapping for people every week. The whole country basically stops for a minute on a Thursday evening, for several minutes actually, 8:00 p.m. to come out of their houses. It's amazing. It's very moving. I had goosebumps when I experienced it. And literally there are people clapping the streets, which is just a morale boost for healthcare workers. So the country's behind them, and these companies are exploiting that. are health heroes by basically using it as a branding opportunity by saying we're giving all this for free, we're being generous but ultimately it's for them to make money out of it and increase their brand later on down the line. That's exactly what they're doing. And the reason I talk about this, Mark, is that it caused this huge Twitter storm. Go and have a look later on. Huge Twitter storm. My tweet got retweeted. Loads of doctors piled in. How can you tell us what to eat? There's nothing wrong with a donut.

There was a diabetes and endocrine concern.

Oh yeah, you're the food police, Dr. Malone. Look at this, a scene. I'm really happy having done a GIF of a giant donut biting into it. And it was pretty extraordinary. But what was good in a way is it really exposed the fact that there's a couple of things that, you know, there are a few things that it highlights. One is doctors still have very poor training and lack of understanding in nutrition. It's just part not medical training. And it's still perpetuating itself. So, you know, we're part of a vocal minority and maybe we're involved in a bit of an echo chamber. in terms of how we're helping our patients. But how many diabetes specialists Mark out there, do you think in the United States, what percentage of them are regularly sending their type 2 diabetes patients into remission with dietary prescriptions?

And for those not watching the video, I have my fingers up as a zero.

It is absolutely, I mean, it is extra.

There's a few out there.

I think there's progress. We know a few of them, but.

You know, but yeah, we still need.

To keep working on it. And I've been involved in writing letters with other doctors saying we need to get compulsory nutrition education in medical schools. They've got publicity. The chair of the General Medical Council, the chair of the Medical Schools Committee all replied back saying yes, things are starting. And the younger generation and younger doctors have been contacting me and they are saying, Asim, you are saying what a lot of people are afraid to say. this is just scandalous. So I think we just need to keep talking about it, we need to keep being advocates for it. I then did a Twitter poll based upon an article I wrote for the King's Fund. I'm a trustee of this health think tank called the King's Fund. I did a blog for them highlighting the issue about doctors need to not just be advocates of looking after the individual patient in their consultation room, they need to think about population health. If you're a cardiologist, care about cardiovascular disease of your community too. What are you doing about that? To stop people coming in in the first place to improve the overall health of the population. And one of the things I wrote Mark, as I said, in my view, doctors who stay silent about the sale of the very junk foods that are driving chronic disease in the first place are in my view in neglect of their duty to patients. I wrote this in the blog. So I put it out as a tweet and I said, listen, this is what I think. This is a blog. So I'm making the case here. Please Please read my blog and then vote. And about 1,500 people voted. And I was still pleasantly surprised. We got a majority in favor. People-- 58% agreed with me, 42% didn't. And that is the most provocative thing one could say. I'm saying that you're in neglect of your duty to patients by not speaking out against junk food sales.

Doctors and healthcare providers need to be on the front lines talking about this. I hope this COVID-19 pandemic, however awful it is, has a silver lining that allows us to recognize this pandemic of obesity and metabolic disease that is really underlying this health crisis and figure out a way collectively to address this. It's what I've made my life's work. I know it's your life's work. And it's just so great to hear you doing this work over there across the pond.

Yeah, Mark, no, absolutely. And I think one thing I would like to say just before we finish is in England we have something called the Seven Nolan Principles, which was actually created by the government in response to a scandal that happened in the mid-90s where it was exposed that for you, maybe it's normal in America, but basically members of parliament were being given cash by vested interests to ask questions in parliament. That's not allowed, and that was exposed. And then the government got a body together that looked at the ethics of all of it, and they came up with recommendations. In fact, these are what's supposed to be followed by all those in public life, which include members of parliament, so politicians, and people who serve whose duty is to serve the public, including doctors, police officers, teachers. And those seven principles are these. And I read them, I thought, how can anyone argue with this? But it made me think, how many people are following these seven Nolan principles? And these are selflessness, integrity, accountability, honesty, openness and leadership. And leadership also means being able to speak out against bad practice and behavior wherever it occurs. And it says that we're all supposed to adhere to these principles. But actually, when I gave a talk in LA a few months ago, I said, just ask yourself, if you're a member of the public or you're a doctor, are you following these principles in your practice? And the reality is, and this isn't blaming individual finger pointing, The system has failed doctors and patients because of all these corporate interests do not allow people. It becomes very difficult for people to actually even follow noble principles in their duty to serve the public.

Yeah, crazy. Well, this has been an incredible conversation. I hope it's been aligned for people to understand the connection between COVID-19 and the underlying metabolic problems we have as a society. You're such a thought leader and advocate and Rebel Rouser trying to change the system. I feel like you're a kindred soul and I'm happy to have you on the team.

Absolutely, a lovely team effort. And thank you for all your work and inspiration. I think we need to just keep shouting, banging the drum and things are changing and they will continue to change but hopefully sooner rather than later. I don't think we're going to let this carry on for another five or ten years. Maybe this will be the catalyst.

So thank you so much for being on the Doctor's Pharmacy. If you want to find out more about Dr. Aseem Malhotra, go to doctor. That's spelled out D-O-C-T-O-R-A-S-E-E-M-A-S-E-E-M.com, check out his book, the Pioppi Diet, which is fantastic. I think I gave him a quote for it. And just enjoy his brilliant writings. He's been published in so many medical journals and newspaper articles. So, check him out. And, I think you should share this podcast with everybody because it will help save your family, your friends, and your community by taking action on what we talked about today. Please subscribe wherever you get your podcast, leave a comment. We'd love to hear from you. And we'll see you next time on the Doctor's Pharmacy.