How the Food We Eat is Killing Our Economy | Doctor's Farmacy with Mark Hyman, M.D. EP16

So welcome Dr. Mazafarian to the Doctor's Pharmacy.

Thank you, Mark, great to be here.

So you're kind of a interesting researcher, scientist, cardiologist who sort of took a left turn somewhere.

Or a right turn somewhere.

Or maybe it was the right turn. You're a cardiologist from Harvard. You had obviously extensive education in public health, but Somehow at some point in your life you realize that food was important and you began to focus your career on researching food and you become one of the leading scientific investigators of what we should be eating and also now run the Tufts School of Nutrition, Science and Policy, which is an interesting school because there's very few schools of nutrition and policy. And so how did that happen? What was the inspiration, the shift in your life personally that led you to sort of go right.

Well, you know, I went to medical school to try to heal people and save lives. And in medical school and then in internal medicine residency and cardiology fellowship throughout that journey, it was so obvious to me that food was the biggest issue facing my patients. And yet, you know, we didn't learn very much about nutrition or prevention other than sort of chemistry and some enzymes. And so that was the first kind of, incredible irony and paradox that struck me. But every other doctor goes through medical.

School and doesn't have that insight, right? It's like food, that doesn't have much to do with disease. You know, maybe extra fat, but other.

Than that, you know, I think a lot of them, yeah, I think a lot of them realize it, but you know, you're so busy and there's so.

Much going on, you know, who knows.

Lots of more cats to do. Yeah, lots of things to do. Yeah. And then the second thing that I realized which really struck me, me was, so I said, well, I need to learn about this myself. And so I started reading and diving into literature and reading everything I could find. And this was in the 90s. And I realized that even the current dietary guidelines then, which were all about low fat, low saturated fat diets, didn't match the evidence even 20 years ago. So that was the second huge kind of wake up for me was that.

The dichotomy between what we're told is the party line of what we should eat and what the science actually that was different.

Exactly. So, you know, the, the, you know, lack of training in medicine for what's the most important issue in medicine, and then the lack of a match between the science and the, the, what's sort of being, being told to people. And so I said, you know, if I want to make a difference, if I want to help people, this is the area I need to focus on, and I haven't been disappointed.

And you, so what did you do? I take a remedial course nutrition or like night school. Yeah, well, I got up to speed.

Yeah. I started with a masters. of public health, a two-year degree. And then I went on to do a doctorate in public health at Harvard and continued with many more courses and then doing my own research and reading and teaching myself and learning from incredible mentors and scholars and gaining from all the sources of information I could. And the things that I learned were amazingly interesting about what we should eat or not eat, with my own focus being on heart disease, stroke, obesity, diabetes, what I call cardiometabolic diseases. Then as you mentioned policy, interestingly as I started to do more research on things like omega-3s and trans fats and healthy carbohydrates or unhealthy carbohydrates, I started getting more and more involved in policy discussions, working with major advocacy organizations like the American Heart Association or international groups like the United Nations or advising parts of the US government or Canadian government. And that was about 10 years later when I was deep in the research. And then I realized that that same disconnect that I had seen for nutrition and guidance was there for policy and practice. And so, you know, the best policy science wasn't filtering to policymakers.

And science wasn't being turned into policy.

Not only that, but but there's science on policy. There's science on what should be effectively done to change behavior and that wasn't filtering to. So, this disconnect between nutrition science and policy science and actual practice and translation was kind of the second thing that struck me. And so, that led my own research and my own work and my interest to expand not only to understanding what we should eat, but how we should get people there, how we should actually change the systems to get people to healthier diets.

That's so powerful. We're going to into policy in a minute, but I want to sort of point out a couple of things about you that are really unusual. As a cardiologist from Harvard, you suggest two things that are significant heresy. One is that saturated fats may not be the boogeyman that we thought they were. Maybe they're neutral. They're probably made out of health food, but they're not terrible. And you wrote that review of what was it? Butter is butter back six and a half million patient years, I think 600,000 patients over many years, and there was no link between heart disease and butter, and there was an inverse correlation with diabetes. And the second kind of heresy is that all calories are not the same, that weight loss isn't about eating less and exercising more, and those ideas are pretty fringe, and you're yet in the center of academia and one of the most respected scientists in the world. So how does that all sink up?

Well, you know, I think that what I try to do, you know, what all good scientists try to do is let the science lead me where it will. I didn't start out with any beliefs or notions about what would or wouldn't be good for us. And in fact, you know, you'll find this funny. My first NIH grant, which was a K award, which is an award to support young investigators who are developing their careers, my first K award, the topic of that award was we know saturated fat is bad for us. And so what should it be replaced with? Should it be replaced with protein or monos or polys or carbs? And this is something that I wrote when I was a cardiology fellow. And then when I started doing the research and I started really going deep into the data, I realized that saturated fat is actually not bad for us. And so my own hypothesis and my own notion changed based on the evidence. I started out intending to understand that saturated fat was bad and what it should be replaced with. And that's not what I found. And as you said, I think it's really important to point out that butter and bacon are not health foods. I've never- I probably wouldn't put butter.

And bacon in the same category though, right?

Exactly. I wouldn't even put them in the same category, but many people do. And that's usually what's on the COVID of magazine articles, and hamburgers and from fast food restaurants. So I think that the work that we've done on saturated fat suggests not that saturated fat's inert, but that it's complicated and that you need to think about the types of saturated fat and the food sources.

And there's such a thing as saturated fat. They're saturated fats and they all have different properties.

Exactly. The concept of saturated fat is a chemistry categorization, which makes a lot of sense for chemistry class, but it doesn't make sense for biology class where all of the different saturated fats have different effects. And the foods that contain them have different effects. And so yogurt is not cheese, is not butter, is not meat, is not nuts, is not olive oil.

All of this contains saturated fat.

Yeah.

And you told me about this fascinating study that was done, I think, in the UK, where they looked at milk products that were homogenized versus non-homogenized. Calorie for calorie, gram per gram, they.

Had profoundly different effects. Right? Yeah, that's a very recent study done by a colleague, Ulf Risserus, and he showed that milk fat globule membrane, which is a natural membrane that's supposed to be encapsulating the globules of fat in milk, and that's why raw milk, you know, the fat rises to the top, and that's why homogenization is done to break up those membrane phospholipids and have the fat and the water mix. That milk fat globule membrane seems to be pretty important to to countering any negative harmful effects of milk fat on cholesterol levels. There's only been one trial done in humans, about 80 people that Wolf worked on, but it's just remarkable that that hasn't been replicated and there's not more study. It's just another.

So the point is that the one that was the sort of original milk we used to get with the cream separating had no adverse effects on cholesterol, whereas the homogenized milk turned out to be not so great.

Yeah, they compared butter, about 15% of calories from butter every morning and about 15% of calories from whipping cream, unsweetened whipped cream every morning. They gave it to people with scones and jam and said, have this for breakfast. And so of course both groups did it, right? You either had butter with scones or you got whipped cream. So 15% of calories from high fat dairy the same fat, the same saturated fat, the same cholesterol. The butter group had all the predicted changes in cholesterol that we've seen many times with people who eat butter. And the whipped cream group had no change in cholesterol at all, which is sort of shocking, right? And it just again shows you how beautiful and intricate the interrelationships and complexities of food and diets are. And it gets to kind of a major theme of of, I think, the evidence and my own work is that this kind of reductionist approach of trying to break down foods into one or two or three things and then make recommendations based on just those reductionist nutrient X and nutrient Y and nutrient Z doesn't work that well most of the time.

And it also speaks to the nature of the quality of food and what happens when you start tinkering it and create processed food that we seem to think is good, like trans fats, and then we We kind of messed up. We thought vegetable oil is good, so let's throw some hydrogen in there and make it look like butter. It's better than butter, and it turned out it was a lot worse.

Well, I think one of the truths in food and nutrition is complexity. And so that complexity even extends to processing. And so there's no simple golden rule. And so even just to say processed foods are bad is probably also, although it gets you a lot of the way there, is simplistic because We need to process most food to eat it. Cooking is processing, taking the hull off, you know, a grain is processing. It's sour. Fermentation is processing. So I think we need to think about optimal processing and learn optimal processing for health. And I think we're just scratching the surface of that.

Yeah, I mean it was fascinating. I had a conversation with Alessio Fasano, who's a celiac expert at Harvard. And I was saying, how do you explain the paradox when people eat gluten and wheat in America, they feel sick. When they go to Italy or Europe, they don't. And he said, well, it's the fermentation process. They actually, instead of this two-hour rapid accelerated fermentation process, the United States, it's like a 12-hour overnight process. I went to a restaurant in Chicago the other day, and they had like a 60-hour fermentation process, and it changes the structure, the nature, the composition, the biology of the food you're eating.

So, yeah. You know, the reason that one of the earliest labor protection laws, several centuries old, was the earliest, I think it was in France, the earliest that bakers could be asked to come into work in the morning. They said no earlier than 4:00 a.m. because it took hours and hours for the yeast to break down the gluten and make bread rise. That's what the yeast were actually doing. The rising of the bread was breaking down the gluten.

So, they actually- It's a labor law that made us all sick.

But, you know, what happened in really, I think the mid mid-20th century was, you know, industry figured out, well, we don't want to wait six hours, eight hours to make bread every time. So, let's put the bread in a heated crucible and mix it up and do it faster and we can do this all in about an hour. And so, then you still got the bread to rise, but you didn't break down the gluten.

Yeah, fascinating. So, I want to dive into the second part of that question, which is about calories, because I think it segues into the policy question. And the basic idea here, in America is that if you eat too much and you don't exercise enough, you're gonna gain weight. And if you can't control your behavior and stop eating and exercise more, then there's something wrong with you. And you challenge that notion that it's not really our fault we're fat, that there's something else going on in the biology of this, that all calories are not the same, then that has implications for policy, food environments, and other things. So let's dig into that one.

Yeah, well, you know, I think that, you know, blaming individual people for obesity and saying that we just have to, everybody has to have better willpower and eat less and move more, would have been like, you know, looking at the incredible deaths from car accidents in the 30s and 40s and 50s and saying, we just have to tell the drivers to drive better, right? We don't need to change the car. We don't need to change the road.

We don't need to change drunk driving.

Yeah, let's just keep the cars the way they are. Let's keep the roads the way they are. Let's keep the speed limits or lack of speed limits the way they are. Let's let people drink and drive. and then just blame it on the individual driver. So what we did for car safety was we changed the product, we changed the environment, the road, and we changed the culture around drunk driving. That's the roadmap to a healthier food system. It's not focusing on the consumer, but change the environment. The environment. The environment, the grocery stores, the restaurants, the supermarkets, the cafeterias, change the products, the foods themselves, and change the culture, in this case, around healthy or unhealthy eating. But I think to get back to calories, the reason it's so clear that this isn't about individual willpower is when we start to see four-year-olds and five-year-olds and six-year-olds overweight and obese now, not only in our country but worldwide.

Three-year-olds with type 2 diabetes in some Native American communities.

It's shocking. You can't say willpower has changed in 20 years in these young kids and it's their faults. There's systematic every country in the world has increasing obesity, every country in the world. So there's clearly systematic global problems going on with our food system. So I think that while the saturated fat being more or less as a class neutral and having variation depending on the food is more and more accepted, I think that's less fringe and actually more widely accepted, I think that the calorie hypothesis is still going full steam ahead in terms of science and policy. And the calorie hypothesis is that it doesn't matter what you eat, all calories are the same. And that's promoted not only by scientists who believe it, but also by industry, because that means if you... It's all about moderation.

There's no good or bad calories.

If you have a colon smile and it's within your balanced diet, you're fine. If you have a donut or a cracker or white bread or white rice, you're... you're fine. And so, I think that that's false.

And, it's not a math problem.

It's not a math problem, yeah. And so, I think, you know, telling someone that their obesity is due to calorie imbalance is like telling a patient with a fever that, well, all you have is temperature imbalance, you know, fix your temperature imbalance rather than saying, well, what's the underlying cause of the fever here? Let's treat it. And so, of course, in a test tube calories matter and, and And I'm not saying that foods and people break the laws of thermodynamics. Calories do matter, but- By the way.

The definition of the first law of thermodynamics is that energy is conserved in a system, meaning a closed system in the body is not a closed system.

Well, you know, there's the microbiome, there's metabolic expenditure, there's all kinds of other effects going on. Of course, at the end of the day, all calories have to go somewhere. I mean, that's true. But the key point is that calorie balance is a downstream effect of poor diet quality. That it's really long term, long term over months to years, the quality of the diet, the composition of the diet is really what drives long term energy imbalance. And so focusing on counting calories is a circular argument. Instead we should be focusing on diet quality. And in particular, you know, I think, and hopefully we'll talk about this, there are really key foods that seem to be linked to relative weight loss, the more you eat. There are foods that you should eat more to keep your weight under control. There's foods that whether you eat them or not doesn't seem to affect weight that much. And there's foods that the more you eat, the more weight you gain. And again, none of these foods are violating, you know, physics. But we have, again, the idea that eating is all about our conscious brain and willpower is false. We have multiple redundant pathways in the body that help us long-term balance our foods and control our weight. So you overeat one day, the next day you probably don't eat quite as much. The next week you don't eat as much. We're always subconsciously kind of balancing ourselves. And the last 30 years, the food system has tipped that balance in a harmful way. Just a little bit. The average person in the United States gains about a pound per year.

30 years. That's a lot.

Exactly. So, I think different foods help or hurt those pathways for weight control. And of course, in the end, calories matter, but it's better for long-term weight control to eat 1,000 calories of good food and 800 calories of bad food.

Let's talk about what the good mess. Because yesterday we were at the Food for Thought conference in Switzerland, Science and Politics of Food, and one of the experts got up and gave a very convinving lecture about how all calories are the same, it doesn't matter where they come from. And at the end, his conclusion was that we should all be eating a low glycemic low diet, which completely contradicts his prior thesis. And I was like, well, how does that sync up? If it doesn't matter what you eat, as long as you don't eat too many calories, it should be fine. So the consensus, literally on the panel of the low fat versus high fat diets, was that everybody should be eating a low glycemic low diet. So Tell us how that connects in with this whole calorie issue and what's been called the carbohydrate insulin hypothesis as opposed to the energy balance hypothesis.

Yeah, so I think, you know, I noticed that too, that there was this discussion about energy balance being the most important thing. And then when all the panelists were asked about consensus, they all said we should be eating low glycemic load diet.

It was a little bit of like what?

And I think again, it gets to what we just talked about. that in a test tube, even in the human body, ultimately calories matter. I think that's what the scientist was trying to say, and we all agree with that, but that different foods influence our body's pathways, our brains, our livers. There was a lot of talk about liver fat, which is really crucial, our fat cells, our microbiome differently. And so, I think the foods that seem to help most with long-term weight control, short-term it doesn't matter, If you want to lose weight for a wedding, fit in that tuxedo, and you want to go on a diet for three months and lose a lot of weight, you can go on any diet you want and count your calories and you will lose weight. And that's why fad diet books sell, right?

Because you can go on a diet.

You'd be hungry and miserable if you do that. Exactly. You can go on a Paleo diet, an Atkins diet, a gummy bear diet. You can go on any diet you want, you'll lose weight short-term, but the body fights back. And so here's where food quality matters. Some foods help the body maintain that drive to weight loss. Some foods hurt the body. And I think the evidence is pretty strong that the foods that help the body are generally less processed, more fiber rich, slower digesting, and rich in phenolics and flavanols and other bioactives which probably help our microbiomes and our cells. That's foods like fruits, seeds, nuts, beans, minimally processed whole grains, vegetables, and I'll pause and say most vegetables are actually fruits. So they're really rich in phenolics and seeds. And then also yogurt, which is rich in probiotics. Those foods all seem to help. And then there's a bunch of foods which seem kind of neutral. Our bodies pretty much accurately account for the calories. They don't really tip our balance one way or the other. Cheese, whole fat milk, low fat milk.

Are those also made of low-fat milk makes you hungry and eat more and gain weight?

Well, again, in the long-term studies we've looked at observationally in adults, they seem to be pretty balanced neutral, low-fat and whole-fat milk. And then the foods that seem to be the worst for tipping us over are mostly starches and sugars. And I say mostly because there's an important exception, but mostly starches and sugars. So white bread, white rice, potatoes, sugar-sweetened beverages. And what's interesting in long-term observational studies we've looked at, the weight gain linked to eating candy is exactly the same as the weight gain linked to eating.

Cereal or white bread or crackers.

Yeah.

When David Ludwig said, you know, below the neck, your body, I mean, above the neck, your body can't tell the.

Difference between, no, below the neck, your body can tell the difference between a bowl of cereal and a bowl of sugar. Yeah, that's true. Yeah. And then the exception in addition beyond starch and sugars is meats. so both processed and unprocessed red meats, not fish, not chicken, but both red meats and unprocessed red meats are also linked to weight gain. And so that goes against the Paleo theory again that it's about eating lots of meats is good for you. I think cutting out starch and sugar.

Is great and that's where Paleo— Most people don't know that if you overeat.

Meat, it turns to sugar. Well, protein and carbohydrate both get turned into sugar in the liver. and fat. Excuse me. Turn into fat in the liver. Yeah.

So essentially what you're saying is that certain foods act differently in the body that have different hormonal, metabolic, microbiome, brain chemistry effects. And functional medicine, we call that, you know, food is not just calories that it's information. So it provides, like, code that you can upgrade or downgrade your biological software with what you eat. And this is essentially what you're talking about.

Yeah.

And it's even stuff that's not caloric, like the flavonoids and phenolics, which are these phytochemicals in food that have properties that affect us and beneficially most of the time. Yeah.

And, and, you know, then it gets even more interesting if you move beyond weight, because we're just talking about body weight. Yeah. But different foods differently alter whether you gain muscle, you gain fat, and whether the fat is subcutaneous, which is still a problem. It's not okay, but it's less of a problem versus what we call visceral or belly fat, which is especially problematic in the liver, organ fat right in the liver. and so, you know, that's also important dairy foods, for example, and randomized trials, they don't change weight a lot, but they lead to more lean muscle mass and less body fat. And that's important.

Are those studies funded by the dairy council?

I'm sure some are and some aren't. And that's a, that's another topic which we're so happy to talk about.

What science can you trust? You know, you, you know what, what I want to come back to that you said earlier was an idea that is often termed nutritionism, which is breaking down food into its component parts, its vitamins, its minerals, its protein, fat, different types. And that allows the food industry to dial up or down different ingredients to say they're healthy and put health claims on the label like lean or low fat or high fiber, heart healthy, right? But what you're suggesting is that's kind of meaningless that we should be focusing on whole foods, that we should be focusing on foods in as natural state as possible. and that it's more about dietary patterns and the overall quality of your diet than these monkeying with these various nutrients.

Yeah, I don't know that overall it's meaningless. It certainly has importance for science.

Well, it's reductions and then you've got to put the story together.

Yeah, we need to be reductionist to try to understand what's going on. And I think it's also good to be reductionist for additives. So added sugar, salt, and trans fat and many other additives, harmful emulsifiers or harmful food colorants or other things. There you can take them away or put them back to the same food. And so there it is important to be reductionist for additives. But once you get to the natural constituents of the food, we do need to think more about the whole food matrix and how that food and the meal and your overall diet it affects health. And, it's complicated. Again, you can't do a simple one-liner story about what to eat because just saying something's local or something's organic or something's natural, if you get a local non-GMO organic fries in a Coke, it's still a fries in a Coke. And, so it's vegan, right? Fries in a Coke are vegan, too. So, you can't use any of these simple buzzwords to get to really what's good good for us. I think we have to think about, you know, and I guess a shorthand is kind of a traditional high fat Mediterranean diet. That's kind of a shorthand I use. But again, that's a bunch of words. It's not one word.

Yeah, and there are a zillion Mediterranean diets, right? So, you touched on something I always want to dig into for a sec, which is salt. Now, we were at this conference and this is Professor McMaster, Sammy Youssef, who was chatting with us and said, you know, I got this whole new data on salt and it turns out it's not as bad as we thought it was. And yet, I've heard you say you think it's as bad as we think it is.

Yeah, well, yeah.

So, and there are initiatives like Tom Frieden and his new initiative to end sort of hypertension about low salt diet around the world.

So, what's your take on that? Well, again, with maybe the exception of fish and Omega-3s because that was the very, very first thing I studied, so I probably still have a little bit of a soft spot for it. I really don't have any preconceived notions about what should or shouldn't be good for us. And so 10 years ago, I was also kind of a salt skeptic. I really thought the data was mixed and not that strong. And about 10 years ago, I was asked to review all the evidence for how food and nutrition might affect chronic diseases for a series of projects, including working with the Global Burden of Diseases study, because they wanted to model and estimate what was going on in the world with diet and disease. And so I went and I looked with my research team and a lot of colleagues at multiple dietary factors one by one and we systematically reviewed all the evidence. We did meta-analyses. We looked for concordance between experimental studies and observational studies and trials. And when we did that for salt, I actually became a believer in the harms of salt. And so while I never hold any belief as 100% accurate, if more data comes, I will change my mind.

I mean, couldn't it be confounded by the fact that, you know, when you're looking at salt in populations and their consumption of it, that it's often associated with processed food that has other adverse effects.

It's hard to sort of separate that out.

Well, so, I mean, if those processed foods usually are, are starchy and they often drive in some resistance, which drives hypertension. So how do you sort that out?

Well, so, you know, again, I think it's, it's important to look at all the evidence. And so I think if Again, I look at all the evidence right now. I think that high salt is harmful. In randomized controlled feeding studies where they keep the rest of the diet the same and just add or take away salt and don't change anything else and they keep the diets the same, salt clearly raises blood pressure. And we know from a range of studies that raising blood pressure raises stroke and causes heart disease. We know that to be true. So those effects are convincing.

And I think everybody agrees. I eat a lot of salt.

My blood pressure is like 90 over 70. well, the effects are fairly small for any one person, so a few millimeters of mercury, so you wouldn't notice the difference, but across the whole population, across generations, it makes a difference. And so regions of the world that have the highest salt intake is actually not the US or Europe, it's actually Africa and China and Asia. They have huge rates of high blood pressure and stroke. So, you know, stroke exceeds heart disease by a long shot in those countries.

My advice to people is always don't, it's not the salt you add to your food, it's the salt that's added.

In packaged food, which is where we get most of it. Well, that's 100% true in outside Asian countries where they use a lot of soy sauce and salt for cooking. That's 100% true. About 80-85% of the salt in our diets in the US or in Europe come from packaged and processed foods. If you just cook yourself and you add salt to your food, it's just not doing anything.

I learned something really cool from chefs that if you just put the salt on after and it's like mere crystal.

Salt, it tastes just as salty with far less salt. Yeah. But to finish the story about salt, I think that everyone agrees and all the evidence is clear that if you get above a certain amount, it's harmful. Above 4,000 milligrams per day, let's say everybody agrees it's harmful. It's like two teaspoons. No, no, that's quite a lot. 4,000 milligrams is a lot. The average US intake is about 3,500 milligrams of total salt.

But in teaspoons, what is that?

I don't know how many teaspoons. I thought it was like two grams or something.

Or something in a teaspoon, but maybe not.

Well, it's about, of just sodium, not salt. It's about two, four grams of sodium. If you, interesting, we have to go in the kitchen and see how that salt is. Yeah. But if, the real question is if you get down too low, is there higher risk? And I think that's the uncertainty in the debate. And there are some, potential truth to that, but personally, I think you'd have to get really low, less than 2,000 milligrams. That's the Goldilocks level of salt, right? Exactly. And, I don't think we're close, I personally don't think we're close to that harmful level yet, but it's controversial.

So, you're one of the few scientists, physicians who've come to the insight that we can't just treat patients in the office and tell them what to eat, that we have to fix the food environment, that healthcare fix. It's not just about better care coordination or better efficiencies or improving payment systems or prevention in some vague way, but it has to do with changing the context in which we eat, the foods that we have access to, and the policies that promote the consumption of more and more of the bad stuff. And we're sort of incentivizing the wrong things. So, one, how did you kind of have the aha? And two, Let's talk about this because it seems like one in five dollars is for health care and about 80% of that is for chronic disease. And most of that is from diet. That if we go upstream, unless we go upstream, we're not going to fix the problem.

Yeah, I just want to highlight and repeat what you said. One in five dollars in the entire US economy is spent on health care. One in four dollars in the entire federal budget is spent on Medicare and Medicaid.

And so, and that's projected to go up exponentially in the next 10 years.

This is swallowing the economics of our country. It's swallowing our government budgets. It's swallowing competitiveness of business. It's pretty shocking if you think about, you know, food, how big of a part of our lives it is, how big of a part of the economy it is. I can't think of any other part of our economy, any other products that we interact with every day, where safety is left up to the consumer. Imagine if you went to toy stores and...

I love this analogy.

Just imagine you went to toy stores and everybody knew there was lots of toys that were unsafe for the kids. There were lots of toys that were okay, not, I mean, a little bit unsafe, but not fully safe. And there are some toys that were really safe. Or you walked into a building and, or you went to buy a house and some houses met earthquake standards and fire standards and electrical standards and plumbing standards. Others didn't at all, not even close. And some houses were kind of in between, some things were met or other things were not met. Or teachers in school, some teachers were safe and were good. The teachers and others were known. Everyone knew the teachers were dangerous for the children in different ways. We would never leave it up to the individual family or the individual person to deal with that mess. We would say, this is outrageous. We want safe toys. safe cars, safe homes, some minimum standards, right? And yet in food, it's the only system where we sort of say, well, it's up to the individual person. We need education, we need labeling, we need dietary guidelines. You know, we just need to leave it up to the person and just not do anything else. And I think, you know, again, that's to me kind of the, you know, kind of the craziest thing about our policy approach so far is that it's all up to to the individual consumer. And so, of course, we need to keep choice and there's a range of foods that people should be able to choose from, but all of them should be reasonably safe. Yeah, all of them.

Well, the challenge with that is that the food industry has polluted the science with studies that confound the truth, that challenge notions that they're unsafe. You know, American Beverage Association funds studies that soda doesn't cause obesity and kind of muddies the waters. And so the argument is, well, who's going to be the, you know, the judge and determine whether or not this is safe or not safe, right? Some people think, well, Twinkie's fine if you eat it once a week, but maybe not.

Well, yeah, I get asked about, you know, what my thoughts on the role of the food industry a lot. And it's like everything else, it's complicated. It's not straightforward. So first, I have to say that the food industry has followed and continues to follow a lot of the really harmful and unwelcome playbook of tobacco, where it's about deception, denial, attacking the scientists, hardball lobbying, softball buying of influence, a lot of the same tactics. But I think at the end of the day, the analogy to tobacco only goes so far. And many of those examples are actually around soda and big soda. There are still present for other foods, but it's really about big soda. I think the analogy with tobacco only goes so far for a few reasons. First, the food company is incredibly diverse and heterogeneous. There's thousands of companies with thousands of products compared to tobacco. Second, I think that with tobacco it's a fight to the death. Whereas with food, we need the food industry. We need their scale, we need their expertise, we need their technology, we need their distribution systems. And when I say big food, I mean from agribusiness to large supermarket, international supermarkets, to restaurants, to manufacturers. People think of the manufacturers, but there's four pieces to big food. And I think, sure. And I think, you know, maybe most importantly we shouldn't forget is the food industry mostly for the last 50 years did what we as public health experts and scientists told them to do. And now in the last 20 years, it hasn't been that long as we've really gotten to new science. we're saying, wait a minute, you know, while you did what we asked you to do, slow down and, and change and refresh. And this is where the problem is that some food companies are slowly trying to do the right thing and trying to pick that up, mostly because they're being pushed by their losses and sales. Yeah. Some because they believe in doing the right thing. Others are fighting and, and drug, you know, digging in, digging in every step of the way. So there's a lot of heterogeneity. But, but I think what's interesting is.

That You know, it's interesting, there was a guy who was at the Milken Conference who was the head of a big food company. He's like, I feel like a frightened dinosaur.

Yeah, all the people I speak to and I've heard from, they see that the food revolution is coming. There's absolutely, the food in 10 years is not going to look like the food it does now. And so, I think what keeps me up at night is not that there's not going to be change, there's going to be change. but that the change isn't gonna be informed by evidence. And so, you know, we need innovation in the food system. We need investment in the food system. But going from Doritos to Cool Ranch Doritos is not innovation. Going from gummy bears to non-GMO gummy bears is not innovation, right?

We need real innovation. We need an Oreo 90 calories instead of 100 calories.

Exactly, not six trillion calories out of the food supply. There's a major food company who wanted to reduce the calories in their ice cream. So they added air, right? So that per cup, there'd be fewer calories. But adding air to food is not going to improve its health. So I think that that's the kind of thing that I worry about.

Calories are the same, sure.

Yeah. So we need to, but the public, I think the biggest thing the public is demanding from their food right now is trust. And big food is not trusted. a wake up call, and that's good that that's a wake up call. And so I think that we don't want to demonize the entire food industry. There's a lot of folks trying to do the right thing. A lot of graduates from our school at Tufts in the industry trying to help them do the right thing. But we also want to work with industry and also work against industry when we need to. Give them carrots, give them sticks, help them and sell healthier, more equitable, more sustainable food. I think that's happening.

I think I've seen these big companies like Nestle and Pepsi just struggling to reinvent themselves. But, it's tough because they've got, I talked to the head of Nestle and he's like, yeah, we have lean cuisine which is mostly carbs because it's low fat and because we call it lean, the FDA says we can't change the composition of it so we can't make it healthier even though we want to. And, I'm like, $800 million business, I get it. These are like big issues for them.

And this is where Mark, government has a key role, right? Because if you leave it up to every individual food company to try to fight the system, they're gonna go under. If they innovate and the other companies don't, they'll go under. So this is where government has really a role to play, to even out the playing field and help these food companies do the right thing.

So let's talk about what those policies are, 'cause there's a lot of things we've written about. And I want to get into some of them. You talked about your best buy policy changes that are going to be not one thing, but a series of things that attack multiple sectors where there's issues, whether it's policy schools, whether it's quality issues, whether it's labeling, whether it's research, all these things are needed in concert to actually shift the whole dynamic from what we have now. But one of the articles you wrote was called the Real Cost of Food. can taxes and subsidies improve public health and JAMA a few years ago? And one of the challenges that, you know, we sort of don't want a nanny state, but in essence, we are creating a nanny state in reverse because we're being a nanny to the big food companies by subsidizing commodities that are wheat, corn, and soy that are almost 60% of our calories. And the people who consume the most of them are the sickest. And of course, we then fund food stamps, which is predominantly, I think it's 70 plus percent of it goes to junk food and seven billion, almost 10% goes just to soda. So we've created a system where we're having price supports for the bad food but not for the good food. And you talk about flipping that upside down.

Well, so you said a lot there. There's a lot of points there. And just what's really interesting, and again, sort of wonderful from a point of view of wanting to study this is that just like there's no single magic bullet to eating and nutrition science shows us that you can't just pick one piece of the diet and fix it and everything's fine. The same is true for policy. There's no going to be no magic bullet. There's a range of solutions that are needed. I think that taxes and subsidies are pretty crucial and I'll talk about that in a minute. But I would go back to your comment about subsidies. There's been this sort of popular that's, you know, kind of urban legend that spread through the media that somehow there's subsidies to commodities that's making the prices cheaper. And I just want to really say clearly that's totally false, that all US policy for commodities keeps the prices high. The reason, you know, what farmer in the US wants their prices low, right? They all want their prices high. And so sugar is a great example. People say, well, their subsidies, you know, and first, most of the subsidies have turned to crop insurance. Crop insurance gives farmers insurance so if they have a really bad season because of drought or something, they don't go under. And so most subsidies now are actually crop insurance for those commodities, not direct cash subsidies. That's still a form of a subsidy, but it's not direct. But corn is a great example. We actually keep the price of sugar high in this country because natural Brazilian sugar is much cheaper than corn syrup, much, much cheaper sugar from Brazilian farms than US corn farmers.

It's interesting because I talked to the vice chair of Pepsi, he's like, Mark, I said, why use high fructose corn syrup in your drinks?

He says, because the government makes it too cheap for us not to. Well, they make it cheaper than natural sugar by putting tariffs on the Brazilian cane sugar to protect corn farmers. Right. Right. So if you took away all the price supports, which actually keep the price high, corn farmers would go out of business, but the market would be flooded with cheap sugar from other countries. So that's just one example of this kind of conventional notion somehow. I don't know, you know, I don't know Michael Pollan, someone wrote about this and it's just entered the, the, but.

Doesn'T allow for the production of more and more of the food. In other words, they pay for them to produce food, even if they, for example, in bad soils or in ditches, and then they fail and they pay this money. I mean, I've heard all these stories.

The great majority of commodity crops in our country aren't eaten by humans. So the great majority of commodity crops in our country go to livestock or go to energy.

So it's- I thought that's what Nixon's policies on Earl Butz were designed to do, which is to drive the prices of milk and meat down because they were consuming these commodity crops. And he was worried about the prices going too high and not getting elected. And he got Earl Butz to change the policies. I thought that's what the whole thing was about.

I would have to go and look at that history. I don't know that. I know about Earl Butz and his kind of green revolution, but the farm bill and kind of the subsidy approach has been oversimplified. There's actually a lot of things in the newer farm bills to promote specialty crops that are called specialty crops like fruits and vegetables to start to promote them. A better approach would be to go to the retail level, right? A better approach would be to go directly to the consumer. And I think we should do that because right now the price we pay for foods doesn't reflect the true societal cost of the food and health care and lost productivity and suffering.

All the externalities.

All the externalities.

Even how we grow the food, how it affects soils and water and climate.

Absolutely. And so it's really not a punitive or approach or a favoritism approach. It's just bringing true market prices to food, right? Food should reflect the true market cost and benefit to people. And so if we taxed most foods, most packaged and processed foods with a flat tax, 10%, 20%, 30%, whatever we could do. And then we used all of that money crucially. We used all of that money to heavily subsidize at the retail level, at the consumer purchase level, or at the farm cost level if you invest in farmer training, new equipment, other things. Then you would use all that money to invest and reduce the price of minimally processed healthy foods like fruits and vegetables and nuts and seeds and plant oils and fish and yogurt and things like that, you would turn the prices up upside down or at least more normal, right? Where you couldn't buy a soda, you know, a 36 ounce soda for 99 cents anymore. And you wouldn't have to pay 50 cents or 70 cents for an apple. You'd pay 25 cents, 20 cents for an apple. you'd pay a dollar for a serving of salmon, right? And you'd pay $1.30 for soda instead. That would change all the incentives for farmers, for retailers, for restaurants, for manufacturers, and for the consumer.

And so, you know, as- Because what's happened over the last 40 years is the price of soda has gone down 40% and the price of fruits and vegetables have gone up 40%.

Well, fruits and vegetables in season are still quite affordable. The FDA, excuse me, the USDA did a nice analysis of that. So fruits and vegetables in season are quite affordable, but there's a lot of fruits and vegetables out of season now. And those of course are really expensive because they're getting shipped around the world. So that's another challenge. But I think that price is clearly one tool that the government needs to use to help address healthier food. And it sounds sort of pie in the sky like this will never happen, but there's now at least a dozen countries around the world that have passed soda taxes. Mexico's passed a junk food tax. Yeah. Unfortunately, none of that money is being used, to my knowledge, for subsidizing healthy foods. And so that makes the taxes only regressive for, in terms of finances for the poor, although it's Progressive for health, for the poor, it's progressive for finances. Yeah. We should use that, the revenue from those taxes to create incentives and systems for making healthy food less expensive while helping farmers, right? We don't want to just make the food less expensive by putting farmers out of business. So I think that's, you know, price is just an absolutely crucial tool. And we've learned from tobacco, for example, how important price is.

So what are your best buy policies if you were willing to sort of be in charge for a little bit and could just do what you wanted? Yeah, I think you're in North Korea, just make a decision or whatever you want to do.

Yeah, well, I, yeah, there's a lot of challenges in North Korea for sure, that maybe food wouldn't be the first thing I'd address, but it would be up there. So I think that, you know, there's probably six or seven categories of policies that I think are really crucial. One is fiscal economic incentives. So like we talked about direct to consumer incentives or taxes, industry incentives, you know, fiscal incentives, give them incentives for marketing and, and advertising and developing of healthy foods and give them disincentives for the opposite.

No, but we shouldn't give them a tax break for spending billions of dollars.

Advertising junk food to kids. Yeah, that's actually been proposed in Congress that hasn't, you know, gained steam or gotten out of committee, but it's been proposed to take away the tax breaks that companies now get for marketing junk food, right? Fiscal incentives through SNAP, the food stamps program. Fiscal incentives is one category. you know, two other categories are crucial is to change the environments in schools and work sites. Their kids spend much of their day in schools, adults spend much of their day at work sites. There's a lot of ways, wellness programming, environmental standards, procurement policies to make schools and work sites places where you and hospitals, you know, places where you can only really get healthy food, food that tastes good and is healthy and is good.

Although our school lunch policy now doesn't exactly do that, right? Pizza is a vegetable and French fries or vegetable?

Well, the 2010 Healthy Hunger Free Kids Act was actually a pretty enormous advance. And so school lunch is much, much better than it was before that. There are still holes, but it's actually probably one of the best policies, food policies we have nationally is school lunch.

50% of schools, you go in and get brand name food on different days. Monday it's McDonald's day, Tuesday it's Burger King, Wednesday it's Domino's. That's 50% of schools and 80% have contracts with soda companies.

Soda. Well, soda is not allowed in public schools.

Sports drinks, which are extremely high in sugar.

No, no. Soda is not allowed in schools. Soda, including sports drinks, competitive foods. They're smart snack standards. And they're not, they're pretty much. There's no sugar sweetened beverages in schools. Yeah, that's pretty much. 100 juice is, is okay. But, but sugar stream beverages are out of schools with healthy, hunger-free kids. Pretty, pretty Landmark, actually. There are, again, some holes, but, but it's pretty Landmark, but But more can be done, I agree. So I think schools, work sites, fiscal incentives, those are three categories. Health care reform, there's a lot to do in health care and we can, that's a whole another podcast, but you know, getting food in the electronic health record, the number one cause of health isn't tracked in the electronic health record. That tells you everything, right? Right, right. That are health care.

First you got to train the doctors.

And yeah, fruit and vegetable prescriptions, medical education, medically tailored meals, changing quality guidelines, changing reimbursement guidelines, there's a lot to do in healthcare reform.

Research and innovation is- Dr. Before you jump on there, just to show you how powerful that is, what you just said, that if you get food prescriptions, the impact can be powerful. So, why would the government want to pay for food? It seems like a waste of money. They people have to eat anyway. But Geisinger did a study where they actually took very treatment resistant type 2 diabetics who were poorly controlled, the most food insecure, they were costing an average of $248,000 a year and they gave them $2,400 of food and some support, social support and help to use the food and learn what they're doing and they reduced their cost to 48,080% cost reduction while improving dramatically the health of the people. And so it's a no-brainer but you can't get Medicare to cover a fruit and vegetable prescription.

Well, so, yeah, you're describing medically tailored meals. And, and what you say is really crucial. About five percent of the population costs about 50 of Health Care. Yeah. All the patients with really complex chronic diseases, you know, kidney disease, cancer, heart failure, AIDS, a range of really severe conditions. And, and several interventional studies now have shown that if you actually give those people food, give them three meals a day, which costs about $20 a day, it's much, much cheaper. You save money because they don't go to the hospital, they don't get admitted, they don't go to the emergency room. And because of that, things are changing so quickly, Mark, because of that, California has just launched a $6 million pilot to do medically tailored meals in eight counties in California this year. And if it works and they see the same results, they're going to extend it to all of California. So change is coming. Change is a coming. Change is a coming. Yeah, and so, you know, healthcare is a fourth bucket, another, a fifth bucket, which I think is crucial for policy is research and innovation. There's a lot we know, but there's so much left to learn. There's so much left to learn about how foods affect our brains, our microbiomes, the differences between different processing methods that we've talked about.

I mean, we could go on and on and on. We don't focus on, you wrote that we spend about a billion and a half on nutrition research and about 60.

Billion on drug and other research. so it's like... Yeah, the numbers are really telling. The federal government itself estimated that all of its nutrition research is about $1.5 billion a year. And that sounds like a lot, but again, all of the country's drug industry research, pharmaceutical research, is about $60 billion a year. Advertising on candy in the US is about $5 billion a year compared to $1.5 billion on nutrition research. So advertising on candy is $5 billion a year, and just purchasing of candy is 50 billion a year in the US. And so, you know, that 1.5 billion is just nothing compared to, you know, what the, the, the true issues going on.

Anyway, I heard some scary thing. We spend more on animal pet care and food than we do on education for our kids.

I have not seen that, but that's, that's really, I would be sad if that were true. I have, amazing. Yeah. So, so we really need research and innovation. We need I think we need a new National Institute of Nutrition at the NIH. The NIH has a National Cancer Institute, a National Heart, Lung, and Blood Institute, all these institutes focused on diseases. We need a National Institute of Nutrition. It's the National Institute of Health. Food is the biggest challenge to health. Let's create a new National Institute of Nutrition. And again, that sounds impossible, but the National Cancer Institute was added to NIH, you know, not that long ago because of just the concerted acts of a few people going to Congress and saying, hey, we need a war on cancer. We need a war on bad food and a victory for healthy food. We need a National Institute of Nutrition. We need public private partnerships and guardrails so industry can fund nutrition research. I think industry has a role to fund nutrition research, but we really have to figure out how to do that transparently and carefully and independently.

I mean, it's tough. You got 40% of the Academy of Nutrition and Dietetics Richter's hard dietetic group in America being funded by the food industry.

It's a challenge. The Trx is a heart-healthy cereal with.

Seven teaspoons of sugar. It makes you want to quit the American Heart Association.

It's challenging. It's challenging. I mean, the food industry has expertise that we need and they also have negative influence that we don't need. And so, how can we use the expertise and minimize the negative? And then I think the last area- Great transparency around and have transparency around food in general. And I think the last policy area, we talked about economic incentives, schools, work sites, research and innovation, the health care system. The last area is sort of quality standards. There are some basic things, the same way we have quality standards for toys or for cars or for houses, we need some minimum quality standards. And the easiest places to start are additives. So we need some quality standards. Basically, the government's saying you shouldn't have too much of these things in food. It's just a minimum standard. We already have done that for trans fat. That's a huge win for the US.

Took 50 years.

Yeah, it took a long time, but we've done it. We need to do that for salt and for added sugar additives. And then we need marketing restrictions on marketing of unhealthy foods to young kids, you know, kids less than, you know, eight or nine.

I think we're one of the few countries in the world that has unrestricted marketing.

Well, we have the First Amendment, which most European countries don't have. And the First Amendment makes business speech protected, including advertising. And it's really, really hard to do something legally that fights against the First Amendment. So they only- They don't allow cigarettes.

To be advertised everywhere anymore.

Well, but several lawyers have told me that if the tobacco companies wanted to fight that and take it to the Supreme Court, which they never did, they'd probably win. But they just don't need to because they advertise in video games, they advertise in movies, they advertise in all these ways. They just don't care about that anymore. It's not a fight they care about. But probably they would win because, again, the First Amendment is so sweeping. But where the First Amendment, you know, can step aside and step aside because of a more important concern is where something is misleading. And so, you know, you have the right to free speech, but you don't have the right to say something that's untrue. Yeah. And so misleading, purposely misleading. And so to kids, I think we can make a strong case that advertising is misleading because they don't understand the advertising.

Yeah, I know my daughter when she was eight, we were taking a walk and she said, Daddy, how come in real life nothing actually seems like the commercials you see on TV? It always seems way better.

Your real life isn't like commercials, Mark. And I was like, this is a.

Very astute young lady. She's got it.

Well, what I tell my kids, I have a five-year-old, a seven-year-old and a nine-year-old and like most parents, they're the delight of my life with my lovely wife. And what I tell my kids is, as one example, I say if food comes with a free toy, you know how bad it is, right?

Right.

I have to give you a free toy to get you to think the food is good enough to eat.

Well, there's one other really cool thing that's happening that you recently went to Washington, DC with our friend Congressman Tim Ryan, and you met with the General Accounting Office. It's sort of stunning to me that there are so many different agencies, often with competing agendas and competing policies that are at odds with each other, that don't make sense, that are contributing to disease and economic burden. For the first time that I know of, there's maybe going to be an inquiry into what those policies do, what their impact is, and how they might be changed to improve our overall care coordination of our government's food policies. Yeah, there's, you know, again, changes are coming.

There's a new working group in the US House called the Food is Medicine Working Group, and it's co-chaired by Jim McGovern from Massachusetts, Shelly Pingree from Maine, and Roger Marshall and Lynn Jenkins from Kansas. It's a bipartisan working group that, again.

Has the title, Food is Medicine, right?

It's all about-- I just get laughed at for saying that. Yeah, it's incredible, right? And it's all about, specific policies like medically tailored meals or fruit and vegetable prescriptions that Congress can pass to recognize the importance of food. And then Tim Ryan, as you mentioned, and Rosa DeLauro from Ohio and Connecticut respectively, have always been champions of kind of public health and good eating and Congressman Ryan also mindfulness and meditation. And they recently sent a letter to the Government Accountability Office just released, I think, June 7th. The Government Accountability Office is kind of the government watchdog, which not only can look for fraud and abuse, but can do deep dives to see where are things going right and where do things need fixing. And the letter they sent to the Government Accountability Office instructing them to review all the policies the government has around nutrition is incredible.

Yeah.

Water is incredible.

It was amazing to me. breadth and depth of the connections that were being made that I'd never seen before on a piece of paper.

Yeah, not from the house. And so Congress has asked the Government Accountability Office to review all of the policies and procedures the federal government has across all of its agencies and understand how the government could influence nutrition to make obesity and diabetes and heart disease and stroke and cancers. less common, what challenges there are, who should they coordinate with, what's working, what's not working, and to give clear recommendations for action. So it's pretty amazing. The government's checking itself to say, what are we doing right and what are we doing wrong? And it'll take a couple years for all of that to be finished, but that's just in time for a new election and a new administration. And those reports will be incredibly powerful.

And you know, it's amazing is that, you know, people think they can't make a difference. And you and I just sat with Congressman Tim Ryan and said, here, this is a problem. Can you help us? And out of that, you know, coffee we had together, something great might happen.

Yeah, I think that, you know, it's, I don't remember the exact quote, but there's, you know, wonderful quotes about, you know, a small number of, Mark, you.

Know, Never doubt the ability of a small number of people to change the world. And that is the only thing that ever has.

Exactly. Thank you for, for filling that in. So I think that that's true and that's been true. I've seen that again and again in kind of the world of food.

That's so great. All right, so last question.

And I should say that you are one of those people who, you know, have had controversy or negative things said about you because not everyone agrees with everything you say. But I think, Mark, you've from the beginning sort of recognized that we need to look at the body holistically. We need to think about the foods that go into our bodies and how they influence us. And I think, you know, you've been saying that for 20 years.

It's all one big great problem.

Yeah, yeah. And so I think that's, you're really quite ahead of the curve in doing that. And I love that you want to talk to scientists, you want to talk to people in policy, you want to bring these views together to make a difference. I think that's really important.

Yeah, yeah, we have to have these conversations about things that matter. And I think, you know, Martin Luther King's quote that inspired that was, our lives begin to end the day, we become silent about things that matter. And people like you speaking up from your position is just remarkable. All right, one last question. Okay, so you're king for a day or maybe a year. And you could change anything in our food system policy. You named a whole bunch of stuff, but if you could sort of focus in on what would be your number one agenda?

I think price. I think price has very, very strong evidence for making a difference. I would pass a single policy that again raises the price of most packaged and processed foods and uses all of the revenues to make healthier foods less expensive. And that's something that food industry could then shift because they could go to their stakeholders and say, hey look, the customers are demanding healthier food and now we have a financial incentive to do it. Reduce our products that are unhealthy and we're going to increase our products that are healthy and we're going to take advantage of this. And it would be price neutral for the government. You could balance the taxes and the subsidies so that, you know, it's kind of neutral for the government doesn't have to pay a dime for it. It doesn't raise taxes at all for overall, you know, income taxes for the government. And it would be pretty transformative, I think.

And it's actually equitable because what's not happening right now is all the externalities of our food system are not in the price. So you're actually kind of fixing that, right? What is the effect on chronic disease and the burden of chronic disease? What is the effect on kids' ability to learn, focus and lost productivity on climate even? You know, what is the effect on climate change and the loss of our soils and depletion of our water resources and even behavior changes, violence and poverty all connected to what we're eating? And so those, those price, prices of those things, consequence of those things are not embedded in the price of the food we eat. Yeah, that's right. So maybe, you know, a can of Coke should be $100.

Yeah, well, we'd have to do the math, but certainly much more than it is now. Well, I think that's one of the.

Efforts we're working on. Yeah, we're trying to figure out how do we do the math and all that stuff. How do we actually make it transparent and so that there's really an authentic free market as opposed to right now, which is a very weird, strange, free market. So thank you, Dr. Mazzaferri, for joining us on the Doctor's Pharmacy, a place for conversations that matter. If you like this podcast, please leave a comment, share your thoughts. You can subscribe on iTunes, wherever you get your podcast, and share with your friends and family. And we'll see you next time on the Doctor's Pharmacy.

Thank you very much for having me.