“Diabetes can be reversed!”
…read international headlines today, based on a randomized controlled trial published in the prestigious journal, The Lancet. Study participants were first taken off their medications for diabetes and hypertension, replaced their usual food with ~850-calorie per day liquid meal replacement shakes for 3-5 months, reintroduced regular foods back into their diets over 2-8 weeks, and also received structured support for long-term weight loss maintenance. The average participant lost an impressive 22lb and a quarter lost 33lb or more!
The clinical outcomes were equally amazing: 46% had their diabetes go into remission, and of those who lost 33lb or more, an amazing 86% had their diabetes go into remission! Almost half the participants were also able to remain off all hypertension medication with no rise in blood pressure. One of the study’s lead authors, Professor Mike Lean concluded:
“Our findings suggest that even if you have had Type 2 diabetes for six years, putting the disease into remission is feasible… and could have extraordinary benefits, both for the individual and the NHS [UK’s health care system]”
Wait a minute: liquid meal replacement shakes? That can’t be healthy right? The evidence suggests otherwise: to a scientist, “healthy” is relative, and when meal replacements are used to replace high-calorie, low-nutrient processed (junk) food, they can be extraordinarily effective and healthy in comparison.
In Part 1 and Part 2 of this series, we discussed how processed foods cause obesity and diabetes, how social networks can band people together to prepare food communally, and how the government should tax unhealthy, ultra-processed (i.e. junk) foods, while subsidizing whole foods, minimally-processed foods, and healthier ultra-processed foods, or what I call “Nutrifoods.”
Nutrifoods: Healthy Processed Foods with Easy Compliance
“Nutrifoods” are ultra-processed foods that are actually designed to be “nutritionally-complete” meals, meaning they provide 100% of the Recommended Daily Intake of all vitamins, minerals, and electrolytes. These usually in the form of powdered or liquid shakes and bars. While the vitamins that these foods are fortified with are not always the same form as those found in whole foods, clinical evidence does show that properly-formulated nutritionally-complete foods can prevent nutritional deficiencies.
When I worked in a hospital Burn Intensive Care Unit (ICU), we used such Nutrifoods in the forms of infant formulas in bottles for babies who could not breastfeed and enteral formulas in feeding tubes for adults who could not swallow, which literally saved people’s lives and sometimes kept them alives them for years. While being hospitalized in an ICU is an extreme situation, Nutrifood meal replacements are also incredibly useful for more everyday situations where time is limited.
As a psychologist, I humorously acknowledge the irony of suggesting that people use Nutrifood meal replacements, since it suggests a sort of regression to childhood. Have we gotten so busy and bad at feeding ourselves, that we need to revert back to what is essentially formula from a bottle? Believe me, when I first heard of Silicon Valley engineers using Soylent to replace food altogether, I also balked. But the more I dug into the research on Nutrifoods, the more I realized they’re at least better than the alternative.
Harm Reduction as a Strategy for Managing Addiction
In the substance abuse world, “harm reduction” is a public health strategy that has been incredibly helpful with substance use and sexual activity. Instead of unrealistically preaching that total abstinence is the only way, it acknowledges people are likely to still engage in pleasurable behaviors. So for those times, the goal is to teach harm reduction strategies, such as clean needle and contraceptive use, to reduce health damage.
Analogously, given the parallels between addiction and ultra-processed foods as ‘designer drugs’, harm reduction is an incredibly helpful strategy for eating as well. Half of Americans regularly skip breakfast, and the half of those who do eat breakfast, end up eating fast or junk food. So the question isn’t whether a fictional avocado omelette is superior to a Nutrifood shake, the question is whether a Nutrifood shake is better than eating nothing or eating carb-heavy cereals or Pop-Tarts. Clearly, the answer is yes.
Let’s End the Diet Debates. Adherence is King.
My colleague, Dr. Sherry Pagoto wrote in a JAMA editorial, “A Call for the End to the Diet Debates”, that the endless debates over which kind of diets are “best” misses the point. The superiority of specific diets pales in comparison to the long-term effects of behavioral adherence. In other words:
“the best diet is one that you can stick to long-term.”The main problem with the Lancet study is that an 850-calorie, all liquid diet, is very hard for non-motivated people to stick to, even in the short-term because they will feel starved and bored of consuming the same thing. However, the positive of the study is that it made eating healthy easier by essentially feeding them so they wouldn’t have to decide what to eat or prepare foods.
The real lesson from the study is that while people should of course eat whole foods as much as possible, alternative strategies are needed given that 100% of people will not eat whole foods 100% of the time. So how can you make it easier for people to engage in a ‘harm reduction’ strategy that reduces the damage from the ultra-processed foods they will inevitably eat in the Standard American Diet (S.A.D.)? I propose an alternative strategy I call the “Realistic American Diet” (R.A.D.!).
From S.A.D. to R.A.D.! The Realistic American Diet
1) Have as Much Whole Foods (as You are Willing to Eat and Able to Sustain) (33%)
Of course, the default recommendation should be to tell people to eat as much whole foods as they are willing to eat and able to sustain long-term. However, for most Americans, we know that whole foods are probably not going to be more than 33% of their calories, because they are either not willing to change their habits or can’t sustain changes past a ‘fad diet’ phase. Now there are some highly-motivated people that can eat 100% whole foods. For that minority, awesome, you can stop right here and bask in your health: Do not pass Go. Do not collect $200.
But for everyone else: while working at the VA, I remember some Veteran patients telling me they believed “salads are rabbit food”, and having only so much success in changing their staples from “steak and potatoes”. So instead of continually arguing with them, we had to meet them where they are at, and allow them to decide to change at their own pace. People’s motivation and ability will vary tremendously on a day-to-day basis, so these numbers are never fixed. Some days you may in fact eat 100% whole foods, some days it may be closer to 10%. The goal is to simply do your best, and to have a backup plan ready when you can’t be perfect.
2) Choose Better Minimally-Processed Foods (10%)
Currently, most Americans eat about 10% of their calories from minimally-processed foods. After prioritizing whole foods, the recommendation should be to have as much minimally-processed foods as possible. However, minimally-processed foods often suffer the same convenience issues as whole foods, so the focus often becomes how to find better varieties. Fortunately, simple substitutions often make substantial differences.
For example, if you walk through any grocery store yogurt aisle, you’ll realize it’s very difficult to find a minimally-processed, low-carb, high-fat yogurt such as Greek or Icelandic yogurt. 90+% of commercial yogurt I find has tons of added sugar, or is strangely low-fat, despite the evidence from 18 countries across 5 continents, showing total fat intake is associated with lower risk of death, and saturated fat intake is associated with lower risk of stroke. Nevertheless, it’s worth the effort to read the nutritional labels to find a brand that works for you.
3) Limit Unhealthy, Ultra-Processed (Junk) Foods as Much as is Reasonable (10%)
When it comes down to the 57% of American calories that come from ultra-processed foods, we cannot realistically expect to eliminate this 0% for most people long-term. While some people do better using all-or-nothing rules, many people still will want to indulge their food cravings occasionally. Thus, we should encourage people to limitultra-processed food as much as they find reasonable, which still allows for a treat every once in awhile, without the guilt that causes so many people to quit diets altogether. I believe that most people can cut down on unhealthy, ultra-processed foods from 57% of their calories to a more reasonable 10%, by replacing about 47% with healthy, ultra-processed Nutrifoods that are just as convenient and tasty, but nutritionally superior.
4) For All Other Times, Eat Nutrifoods as a Harm Reduction Strategy (47%)
You may wonder, “but is it really sustainable to replace up to half of your calories with Nutrifoods like meal replacements shakes?” Science has made a strong case with the Look AHEAD clinical trial, published by colleagues, including world-renowned diabetologist, Dr. Anne Peters. Look AHEAD was the follow-up to the DPP clinical trial discussed in Part 1 that enrolled patients with prediabetes. But this time, Look AHEAD enrolled patients who already had type 2 diabetes. So the patients were actually more ill and more resistant to improvement, and were less likely to lose weight.
Because weight loss science had advanced after DPP, the Look AHEAD researchers tried a more progressive approach. Unlike the original DPP, which only provided lifestyle modification counseling, Look AHEAD researchers encouraged participants for the first six months “to replace two meals (typically breakfast and lunch) with a liquid shake and one snack with a bar (31). They [were] to consume an evening meal of conventional foods (which includes the option of frozen food entrees) and to add fruits and vegetables to their diet until they reach their daily calorie goal.” From month 7 onwards, they were encouraged to wean down to one meal replacement per day, and reintroduce more regular foods.
So how well did this Nutrifood-based harm reduction strategy do? Results showed an outstanding 8.6% weight loss after 1 year, and 6.0% weight loss maintained even after a decade, including reductions in all cardiovascular risk factors such as A1c, a proxy for blood sugar. These long-term weight maintenance results are especially impressive, since almost all other weight loss trials like the DPP show that most patients gain all the weight back eventually.
Behavior = Motivation x Ability x Trigger (aka Make Healthy Eating Easier)
So why was Look AHEAD so much more successful than previous studies like DPP, despite working with more difficult patients? I believe it’s best explained by BJ Fogg’s model of behavior change: the likelihood of a behavior to change is a function of a person’s motivation and ability.
You can either increase people’s motivation by providing coaching, or you increase their ability by providing meal replacements. The latter is much easier and more likely to be successful. Ironically, most behavioral treatments focus too much on increasing motivation and too little on increasing ability. You need to have some of both to successfully cross the threshold of changing a behavior long-term:
ACTUALIZE: Science-Based Foods for Mind and Body Health
Since Look AHEAD, the science has advanced further in showing that low-carb dietsare superior for weight loss and diabetes management. Unfortunately, the majority of Nutrifood meal replacements on the market are far too high in carbohydrates to recommend to anyone who wants to reduce their body fat or blood sugar (the ones in the Lancet study were a whopping 59% carbohydrates). For example, Abbot’s Ensure Original has a whopping 32g of net carbs/serving, and even their Glucerna line designed for diabetes patients still has 13g of net carbs/serving! Upstarts like Soylent are even worse with 34g of net carbs/serving.
Because I could not find anything on the market that I would recommend to patients or even use myself, I was compelled to start a company called Actualize, to develop science-based food and supplements for mind and body health. My mission has always been to “better health through behavior change technology”. In my last company, I helped motivate 100,000 people to lose over 1 million pounds. So this time around, I was driven to give a million people the ability to achieve better health.
I am not ordinarily a self-promoter or product endorser, but I believe so deeply in the mission of what Actualize stands for as a values-based company, that I feel can responsibly share my work with friends and colleagues. The first product is a Nutrifood called Keto Meal, a nutritionally-complete meal replacement shake that is formulated to be low-carb (2g net carbs, 20g complete protein, 18g healthy fat), and high-convenience (can be used to replace any meal, snack, or pre-/post-workout). Whether you follow a low-carb diet or are just low on time, Keto Meal was designed to provide complete nutrition for when you’re on-the-go.
Whether one uses a Nutrifood like Keto Meal, or a simple portion-controlled food like a serving of mozarella cheese or sardines, the future of obesity treatment will rely on embracing technology, rather than running away from it. Or as Muhammad Yunus said, “While technology is important, it's what we do with it that truly matters.”Instead of fighting a losing war against obesity, we must roll with the (insulin) resistance, and leverage technology for both convenience and health in order to change the world.
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