Transcription
Welcome to the Metabolic Link, a medical and science-focused podcast that explores the common thread of metabolism in health and disease. This is where science meets society. Welcome back to the Metabolic Link. I'm your host, Victoria Field, and I am the co-founder of Metabolic Health Initiative, which is the overarching organization, to Metabolic Health Summit, our scientific conference, to this podcast right here, the Metabolic Link, and to our medical education platform dedicated exclusively to metabolic health and therapy, the metabolic initiative. And I am so excited you're here with me on this episode today, listening, watching, because we're really going to be diving straight into one of the hottest and slightly confusing topics in nutrition, ultrarocessed foods. By now, you've probably heard of the term everywhere in the media, in medicine, and increasingly in policy conversations these days. And it's often framed as the driver of chronic disease. But before we can really regulate it or research it or even build health guidance around it, we really need to know what we're talking about. Right? You have to answer the basic question. What exactly is ultrarocessed? And is that definition scientifically useful? To unpack this, I am so excited. My co-host Dr. Dominic Dagassino is interviewing Dr. David Lewig today, a world-renowned physician, researcher at Boston's Children's Hospital, professor at Harvard Medical School, and author of Always Hungry. He recently published a perspective in the New England Journal of Medicine, arguing that the way we currently define ultrarocessed foods may be too imprecise and that imprecision can actually backfire when it drives policy. This is a rigorous conversation. Mechanisms, clinical trials, confounders, and real-world policy. Plus, they get into seed oils, omega-6 versus omega-3, and how GLP-1 drugs may intersect with dietary strategy in ways most people misunderstand. But before we get started, I want to quickly mention that if you're looking for more in-depth exclusive episodes like this one that we don't release to the public and are ad-free, head on over and check out our medical education platform. It's open to the public. It's free to join. And you can just check out hundreds of videos on metabolic health and therapy from presentations to interviews, live Q&A's monthly, and even ebooks. Visit membership.metabolicinitiative.com to check that out. That's membership.metabolicinitiative.com. And you'll also find access there to our private podcast feed where you can earn CMEs on the go if you're a medical professional. So, pretty cool. Anyways, I hope you enjoy this interview with Dr. David Lewig.
>> Dr. David Lewig, thank you so much for being here. I have been digging into your books and I have a list of questions here, uh, especially on ultrarocessed food, a topic that you have been writing about, uh, and I've been reading about with great interest as our medical students have too. Uh, they found your article very insightful and informative. So, the title of your recent New England Journal of Medicine, uh, article is "Ultrarocessed Food on an Ultra-Fast Track: A Perspective Article in the New England Journal of Medicine." And I would love for you to share, uh, what your objectives were for, uh, writing such an article and, uh, the importance on food policy, uh, as we sort of navigate the guidelines on what an ultrarocessed food is and the implications for research too on that.
>> Sure. Great to be with you, Dom. Um, known each other for many years. Uh, so great that we've finally had a chance to do a podcast together.
>> Well, ultrarocessed foods is the topic of the day. We know that, uh, it's gotten enormous amounts of attention in the press. It also was the, uh, featured topic in the "Make America Healthy Again" report on childhood obesity from the White House. It was mentioned a hundred times almost as the main dietary cause of chronic disease. And we all recognize we have a chronic disease epidemic that's strongly related to our diet. Uh, and we don't want to continue to depend upon an ever-increasingly powerful array of drugs and surgeries to manage this. I mean, there's a, a point of no, uh, of no return here. We, we do need to address the causes, uh, that relate to the diet. The question is, is ultrarocessed foods the right target in any public health intervention? You have to choose that target precisely. You don't get a lot of shots at it. And if the target is imprecise, if you miss, you know, the bullseye from a public health perspective, you waste effort. You can cause actual harms. Um, you know, the concern being that you might demonize healthy foods and you could give a health halo to unhealthy foods and, and all while misguiding the food industry and burdening the public. And I've argued that the notion of ultrarocessed foods is so imprecise as to risk causing more harm than good. Now, we all, the term ultrarocessing, I mean, it's, it's a very appealing notion. We, we have images of factories spewing out all sorts of, uh, industrial junk that are poisoning our children and the rest of us. But the devil's in the details, so to speak. So what is ultrarocessing? Ultrarocessed foods. Well, it's part of a system. You know, now this term has been around actually for decades, but it was popularized by a Brazilian researcher named Carlos Montero, uh, as part of a system that would come to be known as NOVA. NOVA doesn't stand for anything. It just means new. And this system was proposed as an alternative to nutrient-based systems. You know, we've been focusing on carbohydrates, fats, salt, sugar, and, uh, Dr. Muter said, well, really, let's forget that and let's just focusing on focus on processing. So he created this system which now has four categories, and I'll just briefly review that. Uh, NOVA one category is unprocessed or minimally processed foods. So that's whole fruits, vegetables, beans, nuts, fish, uh, meat, dairy, and eggs. Um, category two is traditional culinary ingredients, things that chefs would use, so processed foods, but they would use in their kitchen for cooking or baking. And they include many things that we recognize are not very healthy: sugar, refined flour, salt, all sorts of oils. These, these are, uh, category two, and they're so far so good. Category three is combinations of one and two. So, if you take, um, fruit and you cook it down and you add some sugar and you can it, well, that's now a three. So, that's traditionally processed. Things like sardines that you might buy in the store because they have oil and salt. That's three. And then we come to category four, and that's ultrarocessed foods. And this is said to be, you know, the main problem according to this view. So ultrarocessed foods can get that definition with having only one ingredient that's added, uh, one chemical additive that's not traditional, uh, to cooking that dates back 50, 100, 200 years. We don't know quite how long it is, but one ingredient added to a process, to a packaged food, makes it ultrarocessed, regardless of the healthfulness of that ingredient. So if you certainly if you add these emulsifiers or artificial dyes that we don't know their health effects, you know, that's understandable. But at the same time, things like carbonation or fiber or added protein makes a food ultrarocessed. And that gets us to the heart of the problem, which is imprecision. And when we, we see this in the observational studies that, um, whereas ultrarocessed foods overall seem to be associated with adverse health effects, the individual categories have associations all over the place. Sugary beverages, classic ultrarocessed food, increases risk for virtually every disease looked at. But other ultrarocessed foods, such as savory snacks or various kinds of yogurts that you would get commercially, are associated with protection. So this imprecision is a problem when we start to think about actually creating policies that will guide the public to healthy eating.
>> So, can an ultrarocessed food ever be fixed or reformulated? Or is the problem like structurally? Is it the speed of digestion, the softness, the hyperpalatability, the food matrix, the, the macronutrient composition too related to? So, so, what are your thoughts on that? Can, can ultrarocessed food sort of be fixed by a reformulation?
>> Well, let me restate the, the, there are three problems, and the three problems are imprecision, imprecision, and imprecision. So let's take, so these relate to the three fundamental. So I'll just develop a little bit more about the definition because we have to know the definition to understand what we're talking about. So ultrarocess, so the processing, the mechanical processing of the major nutrients of food have different effects based on those nutrients. We, we recognize and have known for decades that the processing of carbohydrates is harmful. You know, so, um, all virtually all carbohydrates break down into sugar in the body, but in intact, unprocessed carbohydrates, that's usually a slower process. So blood sugar rises and insulin rises relatively gently. But you take a whole kernel grain like, um, wheat berries or oat groats and you turn it into white flour, instant oatmeal, and suddenly the body can now digest those foods too quickly, boosting blood sugar and insulin responses. In fact, for people who are wearing continuous blood glucose monitoring systems now, they can see even without diabetes, within five minutes of eating instant oatmeal, you know, you'll see your blood sugar shooting up already. And, um, so that surge of blood sugar and insulin creates all sorts of metabolic havoc and drives weight gain, according to, you know, many lines of thinking, including the carbohydrate-insulin model. But you don't have to actually be an advocate of that model to, you know, to see that the epidemiological studies consistently link sugar and other processed carbohydrates as topping the list for weight gain and, and metabolic diseases.
>> Contrast that to the processing of fats and proteins. So when you process fat, it still is slow digesting and it has minimal effects on blood sugar and insulin. So olives, pretty healthy. Olive oil, it's also healthy. I mean, we're told to that olive oil is one of the healthiest things that you can eat these days. Um, peanuts, peanut butter, there's really no, not much difference. Avocado and guacamole, we could come up with lots of examples. Cocoa nibs versus minimally sweetened chocolate. Chocolate's a health food. Um, and the same with with protein. I mean, a steak might be three times as expensive as a hamburger, but their, their metabolic effects are quite similar. So in failing to distinguish the effects of mechanical processing according to nutrients, you know, it's basically the system throws nutrients out the window, you know, or maybe a better analogy, it's throwing out the baby with the bathwater here. So yes, processing is important, but it's also how, um, those, that processing affects the nutrients, and by disregarding that, we've already created a big problem with imprecision. The second area we touched at, touched on in the beginning, which is the chemical additives. Some are clearly harmful, and we should be much more skeptical of this. And I, I agree with calls to, um, regulate the notion of GRAS, generally recognized as safe, much more carefully. We can't just leave this to the food industry to determine what new products like, what new chemicals they consider safe for the public. That should be government regulation. But at the same time, we know that many additives that weren't used a hundred years ago and will be needed for packaged foods are perfectly safe or even healthful. And so we need to make a distinction there. That's the second level of imprecision.
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>> If you could sort of identify maybe three of the top food additives because this comes up and maybe I'll forget about it later on the conversation, uh, because there's a whole another group of people saying that the additives are like the, the, the bulk of the problem, and I just want you to weigh, like, what magnitude of contribution do you think that these have on sort of the pathological effects of ultrarocessed food, and, and if there's maybe three of them that you know, come to mind? It's a topic I have not delved into, but it's...
>> That are healthy or that are unhealthy?
>> That are unhealthy that should be removed based upon the generally recognized as safe criteria, how they slid into the US food system, like maybe three of them because of...
>> There are many, and, um, I think that the concern by advocates of, um, ultra, the notion of ultra processing, it, it's a valid concern. You know, there are many chemicals, both the individual chemical itself and how it might interact with all of the other chemicals that are being added. You know, we haven't even come to the plastics that get into it. I, you know, these are of concern. We don't know, uh, in most cases, what the long-term effects are. I would say a very good example of that is emulsifiers. You know, small amounts probably fine. Large amounts that are added to foods sometimes to make fairly unhealthy things palatable, um, could be a big problem. We know that these emulsifiers...
>> Is that carrageenan, I think, is one of them? And...
>> Carrageenan is, is a very common, common one, and there are multiple other versions of it. Um, and these, and usually they'll, they may say the purpose on on there, although some of them are unrecognizable. And these, um, don't get well digested in the beginning of the digestive tract and then can disrupt the protective mucous lining. I mean, it literally...
>> Emulsifies the lining?
>> ...dissolves, emulsifies the lining, >> which protects the body from all of the microbes that are in the gut. And that can, at least in theory, lead to something called leaky gut syndrome, where undigested or partially digested substances from our diet get directly into the bloodstream, elicit immune responses, and could that lead to inflammation, autoimmune diseases? So there's, there's a lot of evidence for concern for that. Um, we know that nitrates, um, and nitrites added in large amounts seem to increase risk for gastrointestinal cancers. Um,
>> And, you know, there's again, a long list, but on the other side, there are many additives that are perfectly benign, like, for example,
>> ...sparkling. Mhm.
>> Yeah. This is technically an ultrarocessed food. I mean, what? Seriously? I mean, carbonation, it, it is explicitly indicated as a basis for identifying something as ultrarocessed. And yes, so in the case of sugary beverages, that's a problem, but it's not the carbonation, it's the sugar. And so, again, we have this level of imprecision. And then the third big area is it's really focused on venue. So anything that is made in the kitchen gets a pass, whereas...
>> Oh yeah.
>> ...virtually everything in a package, >> you know, doesn't. Which means that, um, your mother, you know, that a mother could make a 10-year-old, um, child, grade school student, a, a big bowl of, um, corn flakes. She just bought corn flakes with no additives in it, dump on as much sugar she wants, serve it with a big glass of orange juice, and send the kid off to school with blood sugar and insulin, you know, going through this, uh, nasty roller coaster ride, and that's fine. But, uh, if she pours the kid a packaged food, uh, packaged cereal that was supplemented in protein, high in fiber, low in sugar, otherwise just generally whole grain, well, that's probably ultrarocessed. So, again, is this really a sensible way? In fact, when you drill down on, you know, and understand that this system lacks, um, any fundamental guidance through biological mechanisms. It's a system that was crafted together and then revised periodically through the years when there were awkward situations that they encountered. Um, but that it's not really guided by mechanisms. I think you, you come to see this as more of an aspirational notion, somehow harkening back to a time when we ate, um, farm-fresh foods prepared in the home around the hearth. Um, which has probably never been a reality for most of the human race ever. Um, it's a, it's a very lovely notion, but it's not a, it's not a science. It's not a testable science. We see this in the clinical trials unfortunately that, well, in the observational studies, we see the associations go everywhere up and down. So that sort of leads people to then say, well, should we create categories of healthy ultrarocessed foods and unhealthy ultrarocessed foods, which completely undermines the whole concept to begin with? Like, if, if it's such a waste basket, then what good is it? And secondly...
>> For NOVA, yeah, for NOVA. So, so NOVA helped, you know, get the conversation started, and you've identified these extremely important, uh, the heterogeneity of ultrarocessed food in this framework is just really not feasible. And it, and it could significantly impact the trajectory of of research on on the potential for ultrarocessed food. And I know you know researchers that I've spoke with that one did a trial showing like 500, you know, calories extra if you eat ultrarocessed food ad libitum, and I think there's some, there's some discussion that eating those ultrarocessed food, it, like the speed of which you eat the food is kind of linked to your, the hyperpalatability and the, the problem of overeating it. And I wanted to, because that seems to be like, you know, that was a conversation we had, I think, uh, in class the other day, that sort of the hyperpalatability was linked based upon what some researchers are saying, based upon the speed at which you, you eat the food. So that's kind of, you know, and, and it makes sense, kind of in theory, but, you know, you bring up the idea, are protein-fortified ultrarocessed food, is that just like the diet soda of food? But, you know, like a Quest bar or something like that, you know, we can consume that fast. So what are...
>> So, so you've covered a lot of, there's a lot of, um, conjecture in what you just said. So let me, let me first of all, >> um, comment on the clinical trials. So I'm going to, so these range from one day, >> the longest is two months, >> um, and they're a small handful of them. I'm going to quote the world's most highly cited nutrition researcher, um, Walter Willett, um, at the Harvard School of Public Health, who in the New Yorker earlier this year called these studies "worse than worthless because they are misleading." And I think that, uh, our, you know, our field has sort of abandoned, you know, the basic concepts of data analysis 101, where we look to see what are the underlying mechanisms and what are the confounders.
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>> If you look at the diets that are being used in these trials that suggest people eat 500 calories more a day when they're given ultrarocessed person, the comparisons are wildly biased. Um, you know, in my blog, my Medium blog, which I guess you, you can post, I have a, I go through this, including the pictures. And in one, you know, highly cited study, Cell Metabolism, 2019, um, they're comparing foods like a burger and fries with, that's the ultrarocessed, and the minimally processed is salmon and green beans. But when you look at the picture, there's this massive surface of green beans that are spilling over the plate and salmon. Now, like, what has that got to do with ultrarocessing? There's so many ways that those comparisons differ beyond ultrarocessing based on our conventional understanding of diets. You know, the ultrarocessed diet had a lot more added sugar. Um, and of particular concern, it was twice as high in energy density. Energy density is the calories per gram of food. >> Barbara Rolls, many other researchers for a half a century, we've known that energy density has a huge effect on short-term eating behavior. This has been shown time and again. So if you know, if you're trying to argue that ultrarocessed foods have a unique effect beyond things that we already know, and you have these diets biased by dietary factors well recognized that we, that we, that have been established to affect eating behavior, how can you infer that that difference has anything to do with the novel effects of ultrarocessing? And lastly, um, so it leaves the possibility that many of these, that all of these studies, um, have much higher energy density in the ultrarocessed diet. So it raises the question, well, what would happen if you created an ultrarocessed diet that had the same energy density or even a lower energy density? And just this week, a paper in Appetite came out. You, you haven't seen it, I'm sure. Um, I have it right on my desk. Uh, the first author is, uh, person named Alexandra Larkham. The senior author is Kathy Kathy Malanson from Rhode Island. And they compared, um, three meals. And this was just a one-day study, a three separate days, a three-meal crossover study. So, it's again, another short-term study. Um, and non-ultrarocessed, ultrarocessed with healthy foods, according to they, they said, and ultrarocessed with unhealthy or low-nutrition quality foods. And even though this wasn't their purpose, that low-nutritional quality, ultrarocessed diet had lower energy density, as opposed to higher like all...
>> Can I ask one quick question? Did they equate for protein?
>> Yes. Protein was controlled.
>> Okay.
>> Yeah. And, um, guess what? They saw the ultrarocessed food with low-nutrition quality and the lower energy density resulted in lower voluntary food intake, about 100 calories, >> less consumed. Highly significant, statistically significant from one meal. So that would suggest that maybe throughout the day, there would be three, four, 500 calories difference. So what, like, again, if, if you can create ultrarocessed foods that make you over the short term eat more, eat the same, or eat less.
>> What are we talking about here? It's this, this is again, not science. This is this is biased observational data in effect, and, um, it's certainly no basis for guiding nutrition policy going forward. Ultimately, we need long-term studies, and we need studies that control for the things that we already know affect eating behavior. Otherwise, we're just rediscovering, like, the energy density wheel here. Do you propose an amendment to the, um, the current definition of NOVA, or just come up with something completely different that it needs from the ground up? It needs to be, we need to have a more precise definition of this, uh, in particular with how individual foods, maybe they could get a score on their physiological response or something like that. Do, do we need that level of granularity to sort of, uh, put these foods into classification to to really make it, you know, um, useful for food policy, but also for understanding the effects, you know, in, in research? And I think that's, you know, as a researcher, I'm sure that's, you know, one of the most important things, because if we don't have really good research, and if we don't define what an ultrarocessed food is, then we can't trust the research, you know, so what, what...
>> So, so you're asking what, like, what should we do right now in terms of ultra? So I think we have, the FDA has answered that question. So we're 16 years into the notion of ultra processing, and the NOVA system was initially proposed in 2009, and we have proposals across the board around the country and throughout the world to incorporate this notion. And as people are beginning to, they're realizing, we have no idea what the heck we're talking about. And how, and, and why, why do I say that? The FDA came out with in July what's called a request for information to the public. And they said, "Look, you know, we're trying to regulate this. We can't figure out how to do it. Help." You know, if, if at this point, we don't really know how to define it for regulatory purposes, >> we have to say, wait a second, there's there, there's a problem here. And I believe we need to go back to the drawing board. No, which is not to say that we would postpone public health policy. There is lots of actionable scientific evidence based on firm mechanisms. And what are those? Well, in terms of the processing, we know, discussed this, the processing of carbs is almost invariably, you know, beyond removing the husk and, you know, maybe very minimal processing, like converting oat groats into steel-cut oats. Oat groats takes hours to cook. You can cook steel-cut oats in half an hour, or, you know, breads, traditional like European rye breads where you can actually see the grains. Beyond that, we know that the processing of carbohydrates is harmful. The mechanisms are all laid out, and it, these foods top the list. These processed carbs top the list of weight gain and risk for metabolic dysfunction in the food supply. Let's start there. And secondly, let's focus on the chemical additives for which we have evidence of harm. And we can go a step further, which is to say, let's not assume that new compounds are benign, uh, unless proven otherwise. But that said, we can create a hierarchy. Here's the >> biggest items of concern, whereas these other things we know are benign, and why waste the time on it? Why burden the industry? Last thing I'll say about this is we're going to need packaged foods to feed the world. Um, >> you know, we've got 8 billion people. We're all not going back to the farm, you know, to pick our foods and, um, you know, cook those foods ourselves and feed to our families. We need the food industry. We have to guide the food industry in a realistic way. If we put into effect, if, if we suddenly made all ultrarocessed foods, um, you know, unmarketable, which is not, that's not what's being proposed, but let's just take this a step further, the food supply would collapse, and there would be mass starvation. Even infant, virtually all infant formulas are ultrarocessed foods. So I mean, again, this is, it's a, it's a romantic notion. This is not mechanistically oriented, actionable science. And I think that the thing to do is to, I would say, uh, this term ultrarocessing is not useful. Let's focus on the highly processed carbohydrates and the harmful additives, and then we have a precise policy that could actually make a difference.
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>> I totally agree with everything you're saying there. Um, so it brings up the question though, because, you know, ultrarocessed food is not just one macronutrient, or it can be heavy in carbohydrates, but, so if an ultrarocessed food has a low glycemic load, higher protein, higher fiber, is it still, you know, how do you define, is that metabolically healthy or metabolically harmful? And where's the cutoff point? If we make healthier ultrarocessed food, should be scored based upon on, uh, the glycemic load, the protein content, and the fiber, and that you have, you know, uh, uh, I don't know, I bring up a Quest bar, but it could be anything, you know, and, and that's super ultrarocessed, right? So, but it has a higher protein content. Uh...
>> Again, I, I think that, you know, it's hard to disentangle our minds, >> yeah, >> from thinking about processing across the board.
>> Let's, let's, let's just review this one more time. So a sugary beverage is a single macronutrient extraction in liquid form of sugar cane or maybe beet, you know, or corn. That's, it's a single macronutrient, and it's in liquid form. Olive oil is a single macronutrient extraction, highly purified, of of an olive in liquid form. They have opposite health effects. And so we, we have to recognize that the processing of proteins and fats are not inherently harmful, and they can be very useful. For example, if you're a vegan, how many soybeans are you going to sit down to eat? You need things like tofu. Many versions of tofu on the market are ultrarocessed. All of the plant-based meat alternatives are ultrarocessed. But, you know, if you're going to be a vegan and not protein deficient, you need some of these foods. So they have concrete benefits. And so, again, I, I think that in terms of ultrarocessing, we need. And then the last thing I'll say is let's do a thought experiment on this point. Let's do a thought experiment. Think of the common binge foods, the things that you get up at midnight, open the refrigerator, and eat while nobody else is looking. You know, do people do that for olive oil or butter or, um, a burger? Usually not. The common binge foods all have a dominance of carbohydrate. You know, be they popcorn, chips, you know, these low-fat muffins. Um, bread is a common binge food. People don't binge on butter. Butter's tasty, but people tend not to binge on it unless they have a bonafide eating disorder. So, by losing sight of, by, you know, by keeping our our our minds on the mechanisms, we can come up with a useful, targeted policy. Okay.
>> Uh, so I'm trying to, I mean, you've identified the problem really well. So I'm trying to think about, you know, actionable solutions, but I think that'll probably be like a process. Uh, from a scientific perspective, it might be interesting to to sort of ask, like, uh, what hard biomarker would you use to prove an ultrarocessed-heavy diet is impairing sort of the, the metabolism of the patient? So, and again, Dom, so that term is, you can't do that. The term is too imprecise. I mean, I, there are ultrarocessed foods that are consistently associated with health benefits. And this new study, you know, if we're going to interpret it like we interpret the other ultrarocessed studies, we'd have to conclude that ultrarocessed foods prevent obesity because that's how they're interpreting these others that are biased in the other direction. So, you know, we, we, we need to remember that a century of research on nutrients offers value here. We shouldn't abandon it all and get swept up in this, um, compelling. I mean, the term ultrarocessing is so compelling, it's a brilliant marketing word, but it doesn't mean anything mechanistically.
>> So what I hear you saying is that it really hinges upon the, the constituents of the food being ultrarocessed carbohydrates or refined carbohydrates and sugar-processed that should be highly processed. And there should be, uh, scrap the whole NOVA thing, a whole new framework that that incorporates that as probably the primary lever that that is sort of contributing to this, that that we can shift, maybe on, not like, >> you know, on a slider on a rheostat, like not like zero carbs or no carb, but there's probably some kind of threshold of carbohydrates, maybe in a macronutrient ratio, that, uh, that could potentially define a certain level. But, you know, mechanistically, this makes sense. But is there, are there randomized control trials? Is there human data that we could use that exists now to guide that framework for redefining an ultrarocessed?
>> Yeah. Yeah. So let me just add one thing. I, I, I, I, I think the originator, you know, Carlos Montero of NOVA deserves credit, and it, NOVA is a, a very was a useful conceptual model. I actually wrote a paper commentary in JAMA in 2011, so just two years after the initial introduction of the term, featuring and complementing the notion. So it's, it's a useful conceptual model to help us advance our thinking about processing. Um, but it's not an actionable public health framework for the reasons that we've discussed, and the uncritical, um, approach that frankly many of my colleagues have taken to this field. You know, some, I understand that they're frustrated. They want to do something. Ultrarocessing is here, let's just, let's just do something. But we've seen the harms of just doing something. Back in the 1970s and '80s, people based on the same quality data, confounded epidemiological studies, and weak clinical trials thought that we should just eliminate fat. You know, it made so much sense. If you don't want fat on your body, don't put fat into your mouth. What could go wrong? Well, we know what could go wrong. Um, you know, it, it probably the low-fat diet contributed to more disease and missed opportunities than perhaps anything else, and paradoxically promoted some of the ultrarocessed foods that we have today. So we, we, you know, we've, again, let's distinguish useful scientific models from actionable public health policy and as to how to regulate the diet. Let, let's be, let's have some modesty. If people want to come up, and there are, you know, again, some of my colleagues do this, they come up with a global ranking system where one number is going to tell you a product's healthfulness from zero to 100. And some of these are proprietary algorithms. You put, you, you know, you put in the ingredients, you scan a URL, and it gives you a number.
>> This is just wildly simplistic. You know, we know that nutrition is more complicated than that. People vary, um, greatly in their individual susceptibility. Somebody with, um, pre-diabetes, uh, is going to have different needs than somebody who's metabolically healthy. And...
>> You're talking about, sorry to interrupt, but I think you're talking about like, there's various apps out there, I'm not going to name them, where you can scan the barcode for example, and it gives you like a score of the food, and some of it weighs it heavily on sort of the ingredients. So these are becoming quite popular now. But are you talking about with colleagues that you're discussing a scoring system?
>> Well, it's more than just apps. There are, you know, there are scoring systems put out by, um, you know, nutrition experts, >> um, aiming to provide, in, in a single metric, in a single number, a global assessment of a food's diet. And I think that this is again, way too simplistic. It's, you know, the, these historically have been easy to manipulate, and, um, and we, we, we know that nutrition and the interactions between diet and health, and especially when we, the food industry gets involved, is much more complicated. So I, I gravitate against these systems, as appealing as they are, you know, to think that, okay, I can come up with the answer that's going to for once and for all time identify distinguish quality from poor quality and guide the public to solve nutrition-related chronic disease. It's a grand vision. Um, I think it's a bit overly ambitious, and I think we need to have some humility here that the, these are long-term targets, but that if we choose to focus on the key drivers, specific actionable targets, which in my view represent the majority of the problem, well, then we can have real impact. So, we've got to send those public health arrows, which are very expensive to shoot, um, as precisely as possible.
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>> Yeah. And this has major implications for, like, the WIC program or the SNAP program, or what would be a SNAP-eligible item, which is, you know, we talk about this a lot in class. And, um, so given, given the existing, I mean, from what I hear you saying, like, the ultrarocessed food as it exists now should almost be scrapped, right?
>> It's, it's an interesting conceptual model, yeah.
>> Um, it's a non-starter for public health. As we are recognizing that people, you know, you know, it was a great, it appeared a hundred times in the initial MA childhood obesity report. In the second report that focused on strategy, you know, after they had had time to sit with it a few months, it, like, it might have appeared three times because, >> you know, it, it's one thing to envision the food supply as returning to this mythical time again when, you know, when food was simple and we got it from the farms. Again, that probably didn't apply to most people ever, you know, living in cities or, you know, even farmers, you know, would have to eat a lot of poor quality rice. You know, throughout Asia, you know, farmers, subsistence farmers are eating mostly rice, very poor quality diets. Um, but that, um, as, as we're trying to look at how to adopt these, um, concepts into practice, it breaks down, and people don't know how to do it. They realize that, um, there's going to be enormous industry pushback, in part for legitimate reasons, because, you know, if you, you know, we, we do require the food industry to feed us, and if we prohibit too many packaged foods, again, we, we would have mass starvation.
>> Yeah. So we definitely need better definitions, we need better trials, and we need better policy. Uh, what are your thoughts on restrictions to the SNAP program and the WIC program? Because, you know, we, we have to feed people, and we have to do it in a way that's cheap, and we have to do it in a way where the food is shelf-stable. Uh, and, you know, I've been involved in various, you know, feed the homeless programs and, and food drives and food banks and things like that, and seen the kind of food that, you know, they offer there. And I've also seen some gallant attempts at trying to change that too. And it's kind of hard. So, uh...
>> Well, this gets us into some political issues. Um, and I've come down very strongly on one side. Uh, I think there, to be frank, there's been a bit of an unhealthy alliance between the anti-hunger organizations, which admittedly, you know, hunger is a major, still a major problem in the United States, and we're in the middle of a budget crisis and a lockdown, and, uh, if this continues, you know, SNAP will be affected, and hunger will surge. But, but there's chronic hunger, and there's understandable focus against it. But many, uh, and one key anti-hunger group has allied with the food industry in, um, agreeing to, um, oppose policy measures that would institute basic foundations of nutrition quality in SNAP and other, uh, public food assistance programs. I'm, I disagree. I've disagreed in writing, including in several papers in JAMA and elsewhere, that, uh, these public assistance food programs, you know, should not be providing sugary beverages. I mean, um, you know, we, the purpose of these programs are to promote nutritional well-being, and not food industry profits. And so, I think it's >> a legitimate minimum requirement. I would like to see that happen. I think that we may have an opportunity to do so, um, in the, you know, coming months and years. But absolutely, we, we need to base, um, we need to increase the total amount and focus the funds that we're putting in to promoting high-quality foods that are going to prevent nutrition-related chronic diseases.
>> Yeah. That sugar-sweetened beverages seem like the low-hanging fruit to just avoid to have have that reimbursed. So, what's, what's the most, uh, overrated, quote-unquote, healthy food like in the supermarket today that, that you think, like, your opinion on that? Your...
most overrated healthy food. So, I think I think you know there's probably a lot to to choose from here, but um >> well well this we could connect this to our prior conversation. Yeah. >> If the processing of carbs are the big problem and the processing of the fats and the proteins are much less so, then a highly processed technically whole grain product might carry a health halo but differs very little from white bread or a bowl of sugar for that matter.
When you process the grain, even if you've left some of the fiber and wheat germ there, and typically these whole grain products don't do that. They actually separate everything. So, you've got white flour in one production line, the wheat um brand in a second production line, and the germ in a third. And then they get recombined in some amounts that are said to reflect the original grain, and then they're marketed as whole grain. But metabolically because it's so processed and the fiber is no longer protecting the starch that food gets digested almost as fast as white bread even though it's marketed as a health food.
>> So uh I mean to pivot a little bit and this may be outside your wheelhouse but maybe not from a policy perspective. Uh do you think that the problem lies with um I mean it's mostly probably economic but from a farming perspective right I grew up farming I grew up growing soybeans and wheat and corn and all that stuff and yeah we got subsidies and then we grew Monsanto products and things like that and used all the chemicals. Uh do you think that this is a solvable problem through policy at a higher level like taking a step back into the farmer where subsidies can go to regenerative farming, smaller farms and we could start maybe not out of the gate but maybe incrementally where we start shifting some of the policy to give subsidies to small farms to regenerative farms. And that's a that should be like an unambiguously, you know, important step in the right direction in changing food policy. Do you what's your thoughts on that?
>> I agree. Um we, you know, we I spend some time in Denmark, do some consulting there. >> Lovely, lovely little country. Um very peaceful politically. um although it's just 6 million people but all through you know throughout most of Europe the food supply um although certainly industrialized is uh you know a lot more natural you know the foods are tastier um they you can have um processed foods that retain um you know that connection to the farm farm um and they have local more local distribution networks. These are all consequences of food policy investments and infrastructure. you know, back in the 1970s, I think it was Earl Buts, who, you know, perhaps for legitimate reasons was concerned about enough calories in the diet and put together a series of um policies and programs that resulted in the commodity-based diet that we have today, you know, which favors massive monocrops of corn, um, soybeans, wheat, and rice. um that are making it very attractive for the food industry to produce these highly processed um foods of low nutritional quality. But, you know, that's all reversible or at least correctable. um we're not going to do it overnight, but with um a strategic plan. you know, not, you know, we, you know, we can't be flipping back and forth based on the political wind of the moment. But if we have a vision for creating a food supply that that, you know, doesn't put unrealistic demands on the food industry, gives them some flexibility to innovate, but encourages and subsidizes um the more healthful foods. In fact, I have a yet one more commentary in JAMAMA that suggested that we if we taxed had a very small tax on the unhealthy processed foods and we put them into subsidizing whole foods, we could make many of the foods that many people can't afford, whole foods, highquality proteins and the like much more affordable and we at the same time would be shifting the food supply because farmers would have an incentive to make more of that. So I think that's a a long range vision >> but with a strategic >> Yeah, I like that idea. So and that was a question I had actually uh when it's if you could pass one law about ultra it was about ultrarocessed food but about certain foods in general uh would it be a tax where you generate a revenue for these kinds of programs for example? Would you would you pass a law for a tax, a warning label, or market bans to kids for for certain foods? I mean, maybe all three, but if you could uh if you could choose one, would it be the tax, the warning label, or the market bands to kids? And which would have the >> the biggest impact in your mind?
>> You know, I think it's sort of like driving a car. You ha you can make changes to the wheel and it might improve your direction at that moment, but you have to know where you're headed because the road is going to change. You have to see, you have to have a vision for where you want to go. And if we want to go to a food supply that aligns profits for farmers, farmers going to need profits and the food industry needs promise profits. We live in a capitalist society mostly. Um but we so the government's role is to align the profit motive with the public good or in this case public health. If that's the case then we need all of these things. Now as to what comes first is a political tactic. It depends on negotiations you're going to make and you know what you know coalitions you can form. um you know, but we we have to know where we're going to go. And if we're really going to go there, we need everything in time.
>> And and that that requires money, that requires funding. And where's that funding going to come from? And maybe that funding could come from the tax like maybe if we tax uh sugar sweetened beverages and things. We know I remember researching this subject quite a lot. Like if you tax something, people will, you know, and jack up the price on it. People will spend less. They will consume less of that. And then at the same time, you're generating, you know, revenue for these programs that could, you know, uh, change policies.
>> Yeah. You know, it used to be, uh, the taxing was sort of a argument from the left and the right says, you know, you're just interfering with free commerce. But now, you know, with tariffs on everything Yeah. Um I think all bets are off and certainly people on the right are now embracing the notion that we could use e these economic levers. So taxation of unhealthy foods is actually from my perspective a very capitalist approach. There's something called a paggovian tax. PGovian tax well established concept in economics. I'm not an economist, but it says that basically you have to pay upfront for the costs that you're going to impose on others over the long term. So smoking is a perfect example. If you smoke and you get cancer 10 years from now, we have to the public has to take care of you one form or another through Medicare or Medicaid and so you pay a tax and that's also going to reduce smoking, but it pays it forward. So I think that we can do that on unhealthy foods if we can agree on what the unhealthy foods are in the short term with the understanding that over the long term this will more than pay for itself. You know we have hundreds of billions of dollars in diet related disease um which if we could reduce in substantial measure would free up a whole lot of money for profits for everybody. Yeah. Yeah.
I mean, there's so much to unpack. I mean, we've covered Well, we've been talking about the ultrarocessed food for about an hour now. I want to pivot because I have some things that I'd be remiss if I didn't bring up, but uh but I think you've clearly defined in your the perspective article the problem with the NOVA system and um and I think that the path forward is to have a different system. uh or maybe one other I had a question related to you know satiety per calorie or something. No, that was a little bit too convoluted but I'd like to jump to a question that many people have been asking me about uh at least three asked me to ask you this question. Uh, are seed oils a major driver of ataposity or a distract and a distraction from the refined starch and sugar sort of ideas that you've presented out there? And I I I don't remember you talking much about seed oil. So, I'd love to hear just like your general thoughts on that. We don't have to dive too deep into that. But but as you know seed oils being also a major contributing caloric you know uh component of ultrarocessed food. So there's a camp that's saying that the ultrarocessed food hyper palatability is sugar and fat and definitely fat and the seed oil and the seed oils contribute usually the the major fat source and they would point to the seed oils as being the contributor to the weight gain and everything associated with you know the epidemiological data showing you know the dangers of ultrarocessed food linked to the seed oil. So would like to just get your general thoughts on that.
Well, uh, the last point, um, the dangers of ultrarocessed foods linked to seed oils, >> the hyper palatability and the overconumption of >> that's not there's no evidence for that particular connection. Um, the the the item that is most consistently linked and drives much of the relationship between ultrarocessed foods and adverse health outcomes has no seed oils. It has no fats at all. It's sugary beverages. If you removed sugary beverages >> from the equation, the whole association with the other major contributors is processed meats. But I do want to say that the processed meats is quite a big category. You know, we're not talking about just hamburger. >> We're, you know, we're talking about things like um bacon or sausages that have as much sugar added as it has protein. So, um, you know, you can get beef jerky where sugar is basically the the main ingredient and so there's a ma there's a wide or chicken nuggets is another example. Yeah. You know, there's more carbohydrate than protein in a chicken nugget. So, given that that's a very that's a heterogeneous category, >> the driver of these associations is the sugar beverages. Now, let's come back to the big topic of seed oil. So, um, we need to distinguish seed oils from omega sixes and then talk about processing. And we'll do this, we're getting I think we're getting toward the end of our time together, but I'll try to do this succinctly. Um, so seed oils for the most part are high in omega-6 fatty acids. Omega-6 fatty fatty acids are a polyunsaturated fat. The other major one is omega-3s and we think of those as coming from like fish oil, although they also come from they're short chain versions of that. Both are essential. You need both of these to live. You know, the body can't make them. The concern is that the diets that we're now eating are vastly higher in omega6 and lower in omega-3 than might have been the case for humans up until the last 50 years or so. And that, you know, that's true. And simplistically, the omega sixs are linked to inflammation and the omega-3s to anti-inflammatory effects, although they're mixed. And omega sixes have many different effects and they can go through multiple pathways. And the third complication is what happens to them. So if you take the seed oil and you know you cotton seed oil for example and you put it into a fryer and you're cooking French fries for days with this vat high temperature it gets oxidized. Those omega-6s, like omega-3s, are delicate molecules, easily reactive, and when they react, get oxidized, develop all sorts of toxic inflammatory substances that you don't want to be eating. So that's so it's you know there's a distinction between canola oil which you know was prepared under good conditions and you know is fairly natural versus you know seed oils that have been treated to harsh conditions and are contaminated. So lastly, I'll say then what is the episo? So the observational studies um they're pretty clear. The more that people eat um the healthier they are of omega6. Of course that doesn't say exactly where these are coming from. Um actually the last thing I'll say is that there are clinical trials where omega sixes have been driven up really high and you begin to start to see adverse effects. Although the people who are advocates of omega6 say, "Well, that's not really the problem with omega 6. It's that you've driven omega-3s down to low." >> So, it's an emerging topic. I don't I do I personally would avoid seed oils that are that have questionable ancestry. If you don't know how it was treated, if it's could have been high temperature and oxidized and sitting around in friars, that's a big problem, I think. Um, but I I I just don't see the evidence that omega sixes are public health enemy number one >> for diet. >> And I also would say I would also say that in terms of just general common sense, we would want a a reasonable balance of the two. You know, I wouldn't want the omega sixes to be crowding out the omega-3s, which most people don't get enough of.
>> Yeah. I mean with that I maybe one quick question related to that in the balance of omega sixs to omega-3s. Do you think there's enough evidence out there that some argue that omega-3s like using the omega quant test for example uh which I've done in various tests that that should be almost part of standard blood work like your omega 3 to omega 6 ratio or omega you know DHA EPA levels in your blood like that should there's enough data on that that that should be like almost part of a standard panel and you know for cardioab cardio metabolic biomarker. So, do you think that what are your thoughts on that? Because there's a lot of discussion with omega I mean major podcasters have done like three-hour discussions on omega-3s and and you know the takeaway that I've hear is that like these are so important that it should be like part of standard blood work.
>> Yeah, okay. This the simple answer is that you know again um there's an interesting disconnect between the amount of these things you eat and what happens in your blood. So some people can eat a lot of omega sixes and their blood levels don't go up very much. We're we vary and we know there are >> a number of >> genes that control specific enzymes that vary a lot between people. So that some people you know um will react quite differently and so these blood tests provide some insight into that. Of course we have to recognize that um you know just because somebody is claiming to measure something in a commercial laboratory doesn't mean that it's being accurately done and informative. Many of these are being done without any kind of um oversight or quality control. Ultimately, we want to be able to study how these tests predict health outcomes and can guide diet. And that's an interesting area of research. I I think we need more study there.
>> Okay. Well, one last question because I know we're coming up on time. Uh, and I had a lot more, but the the GLP-1 drugs, uh, do you consider them like a metabolic reset or kind of a lifong metabolic crutch and maybe some some issues that are arising from the research on uh, the GLP-1 drugs and maybe dietary ways to augment or enhance their application?
>> Well, I think the first thing that we have to say is these drugs are game changers. I've been in the field of obesity for decades, and everything that we've had up till now was both less effective and had many more side effects, including life-threatening side effects. Now, these drugs do have important side effects. In some cases, they can be very serious, like, you know, paralysis of the gut. Um, but for many people, it's been a gamecher. They're very, but they're very expensive. um they do have adverse effects and um you know the we don't ultimately know what the consequences of putting people on these drugs say early in life and keeping them on them for years to come will be. I think we all recognize that um we despite after the initial excitement about these drugs you know the pendulum is moving a little in the other direction and we realize we need diet too. Um, I wrote a paper with a person who gets credited for discovering GLP1, a Danish fellow named Yens Holst. And so he comes from the drug world and I come from the diet world. And we both met in the middle. And we said, well, we need both. You can't rely on these drugs as a public health issue. And we took a step further which is relevant to this conversation in that we argued that these GLP-1 drugs work in similar me with similar mechanisms as a low carb diet. See people simplistically think that these drugs raise insulin levels based on their effects in the test tube on beta cells but that's >> they do but not long term not your fasting insulin. Yeah. Okay. So yeah that's a question I had. So the one question specifically is does the GLP-1 drug efficacy is that evidence against the carbohydrate insulin model? Two people asked me to ask you that question.
>> It's the it's the opposite. So again, this is just a fundamental misunderstanding of >> in the test tube with beta cells. It is a weak increent. So GIP that's the one that really stimulates >> um GLP1 is has a weak effect, but it does affect beta cells directly. But it has a much more dominant effect in slowing gastric emptying. And this is the big side effect that people have. In some cases, people on these drugs when they go to surgery, like they've been fasting for 36 hours and they still have food in their stomach and that's a risk for aspiration. So because these drugs slow gastric emptying so much and they also slow down the actions the paristalsis throughout the upper gastrointestinal tract. um the carbohydrate you eat gets digested a lot slower and um carbohydrate is the dominant stimulus for insulin. So after the first dose of the GLP-1 drug and this has been known for decades after the first dose of GLP-1 or the drug in somebody who's eating actual mixed meals their insulin drops. it drops immediately and and long term because again of this um dominant effect in slowing gastric emptying and in that sense and many other ways it looks like a low carb diet. A low carb diet, >> you know, decreases the surge of blood sugar after you're eating. It lowers insulin. Um it uh increases leptin sensitivity. it seems to have benefits on um helping to maintain metabolic rate with weight loss although that's an evolving area. Um and so we proposed that um the combination of a low carb diet and these GLP-1 drugs would produce synergy. Synergy is something that everybody looks for in medicine because it means a little goes a long way. You have pay less for the drug because you don't need as much. you don't have as many side effects, the long-term risks of complications are reduced, and you have something to transition to if you don't want to stay on these drugs for life. So, I actually have a >> trying to get funded a trial that will look at this. Um, you know, it's an expensive trial, but still a fraction of the cost >> of a phase one of a phase three drug study. Yeah, I think that's an extremely important trial because yeah, these I mean the drug the people who promote and sell the drugs, you know, they're not advocating for an off-ramp, right? So, it's not gonna it's not part of their budget model. And I think that a low carb diet could reduce maybe someone could micro dose a GLP-1 and then that could be the logical off-ramp in addition to the synergy that you're talking about here. So, so yeah.
>> Yeah. So in summary, the the effects of the mechanisms of GLP-1 strongly support they do not oppose the carbohydrate insulin model and I guess we we'll put some links into your >> okay >> program notes so people can read up a little bit more on this.
>> Well, thank you David. I really appreciate your time. I know you're very busy. Thank you for your wisdom and your insight on all this and all the publications and books that you put out there to educate the public in addition to the the research that you're doing. Uh, real quick, where can people get the most information from you? PubMed, I'm sure, but maybe some recent books that you could >> Yeah, I uh Well, uh, actually, I'm approaching the 10y year anniversary of the book you see back there, uh, Always Hungry. Um, >> I got that book, uh, is >> great book available. And, uh, and then the follow-up cookbook, Always Delicious, which I did with my wife, who's a professional gourmet chef. So, uh, a little collaboration. People can find me on social media at David Lewig, MD. Um, my website, well, we we can link these things below and I'm I'm happy to um receive emails.
>> Thank you. Appreciate that. Well, thank you again for your time and sharing everything. We covered a lot of ground and I think it's going to be really informative and helpful for people following these topics. Uh, thank you again and look forward to hopefully seeing you soon and maybe doing a follow-up as the research advances on these topics.
>> Great great to talk to you and and uh keep up the great work on your end too.
>> Thank you. Appreciate it.
>> Thank you for watching this episode of the Metabolic Link. This discussion highlights why precision matters especially when concepts like ultrarocessed foods begin shaping research, clinical thinking, and public policy. Mechanisms matter. Definitions matter. And getting them right is essential if we want real progress in metabolic health. Again, if you're interested in more in-depth adfree conversations like this one, you can find exclusive episodes and a ton of additional content at membership.initiative.com. Head on over there. 7-day free trial. Oh, and Dom is joining us January 2026, my co-host, to host a live ask me anything Q&A. So, if you're watching this and it's January, definitely check that out. It's just membership.mabolicinitiative.com/domm. And I hope you join us and hope to see you there. Thanks so much for listening and watching the metabolic link. Do you love learning about metabolic health? So do we. It's why we created the Metabolic Initiative, an online educational platform providing evidence-based education on metabolic health and therapies for health care professionals and the general public. By joining the Metabolic Initiative, you'll gain access to hundreds of expert lectures, interviews, panel discussions, and even private episodes of the Metabolic Link. CMEs are available. Go to metabolicinitiative.com to get started. And as always, thank you for listening to the Metabolic Link.