We have a war between two food systems, a traditional diet of real food and ultra-processed food
…tweeted Dr. Robert Lustig, a fellow Professor at UCSF School of Medicine. He’s right. But I replied with the inconvenient truth few are willing to admit: “processed foods have won the war.” That isn’t to say we should be hopeless about the obesity epidemic, but we must soberingly admit our current strategy for curbing it is doomed. But there is another way. When other strategies fail, clinicians sometimes use “paradoxical interventions” where the problem is prescribed as the cure. So this is a radical manifesto about how processed foods have not only caused the obesity epidemic, but can also cure it. To paraphrase Robert Frost:
“The only way out is through.”
S.A.D.! The Standard American Diet is 2/3 Processed Foods
Dr. Dariush Mozaffarian, Dean of the Tufts School of Nutrition, and colleagues published one of the most eye-opening studies on the Standard American Diet (or what I humorously like to call “S.A.D.!”). Astonishingly, they showed that only 1/3 of calories come from ‘unprocessed’ (whole) foods anymore. The other 2/3 of calories come 10% from ‘minimally-processed’ foods (like cheese, which one could potentially make in a kitchen) and a staggering 57% from ‘ultra-processed’ foods (like Cheeze-It crackers, which can only be manufactured in a factory).
The evidence is clear. By a 2:1 margin, processed foods have dominated whole foods in America like Mayweather over McGregor. It’s no wonder, processed foods are widely perceived as cheaper, tastier, and more convenient than whole foods. But what people don’t fully realize is that processed foods are actually a dominant technology developed by a multi-trillion dollar food industry, and we are never, ever going back to the pre-industrial way things were. We live in a world of transformative technologies, and in a nation were 98% of Millennials own ‘smart’ phones, our society will clearly never go back to ‘dumb’ phones and pagers. So why do we expect any differently with food?
What Works for Some, Does Not Work for Most
For an individual, it is obviously possible to eat 100% whole foods. There are lots of great success stories of people who transformed their entire diets, lost 100 lbs., got off of their medications, etc. But just because “it worked for me”, doesn’t mean it will work for everyone else, because not everyone can “just do what I did.” Any clinician who has actually worked with thousands of patients know that different people have different levels of readiness to change, will require different approaches, and as a result, some will simply do better than others. This is not to downplay the importance of individual responsibility. As I tell my own patients:
“It’s not your fault that you came into my office, but it is your responsibility to walk out better.”
Thus, we must balance individual responsibility with acknowledging the data that most don’t succeed on their own. Educating the majority of Americans to only eat whole foods, without addressing how to manage processed foods, is like teaching “abstinence only” sex education, and expecting most people to never engage in sexual activity until marriage. Educational strategies that don’t acknowledge human behavior are hopelessly ineffective. We must acknowledge people indulge, and teach them how to reduce harm when they do so.
Convenience is King, and is More Sustainable Long-Term.
The science suggests that though doctors admonish their patients to “eat right and exercise”, this advice alone generally fails to work. In fact, in the placebo/control group (designed to show no effect) of the Diabetes Prevention Program clinical trial, patients were counterintuitively instructed to lose 5-10% of their body weight. That’s because researchers knew they wouldn’t lose any weight anyway! Even the lifestyle (intensive counseling) and metformin (medication) groups, which did lose weight initially and significantly slow the onset of diabetes, eventually regained all the weight lost they lost after a decade. The temporary weight loss was still beneficial (reduced diabetes risk by 34% over 10 years), but would have been more powerful if the weight loss was maintained:
That’s because the law of inertia suggests any clinical treatment for obesity that expects patients to significantly do more work, instead of less, will eventually fail for most people in the long-term. Eating 100% whole foods was only sustainable for a society in a pre-industrial farming era, where the only foods we could eat were the whole foods we hunt, picked, and planted ourselves (that’s the real Omnivore’s Dilemma. Sorry, Michael Pollan).
But most people no longer have the time, energy, or resources to eat three home-cooked meals per day. Modern households are no longer inter-generational, with fewer grandparents or stay-at-home spouses to bear the responsibility of communal food preparation. Even when TV dinners were introduced in the 1950s, they “came as a great relief for housewives burdened with baby-boom offspring.” Convenience is king. But it’s not just because we don’t have time to prepare whole foods, it’s because processed foods are so behaviorally irresistible.
Obesity is More of a Behavioral than a Biological Problem.
In the medical community, obesity is considered a symptom of a larger ‘metabolic syndrome’, which shows up externally, as belly fat, but also internally as high blood sugar, high blood pressure, high cholesterol, and high blood fats. But these are actually symptoms of the root problem. While obesity is a complex, biopsychosocial issue with no easy explanation, the explosion in obesity rates suggest there’s something radical going on. If you look at this CDC time lapse of obesity rates from 1985-2010, most states went from <10% obesity to >30% obesity in the span of only 25 years!
So what’s going on? The main driver is that the way we eat has changed dramatically: with people cooking less, eating out more, and relying more on processed, carbohydrate-rich foods that drive insulin resistance. Thus, this data suggests that obesity is more of a behavioral problem than a biological problem. These foods also serve a psychological need. Despite the current opioid crisis, eating is actually America’s favorite narcotic: with 38% of adults reporting “they have overeaten or eaten unhealthy foods in the past month because of stress.”
Most Ultra-Processed Foods Are ‘Designer Drugs’. We’re Hooked.
Americans are victims of an ‘obesogenic’ environment that has them hopelessly hooked to the most irresistible designer drug the world has ever known: ultra-processed foods. In Waistland: A (R)evolutionary View of Our Weight and Fitness Crisis, psychologist Deirdre Barrett argues out that human beings evolved to crave certain stimuli: fats, salts, and sweets, to help us survive and thrive through harsh times. “Big Food” companies exploited these natural cravings by designing processed foods that are far fattier, sweeter, and saltier than anything that normally exists in nature. Thus, processed foods are “supernormal stimuli” purposefully designed to be addictive, and effectively outcompete whole foods on our tricked taste buds.
Lest you think this is a conspiracy theory—Big Food industry scientists have admitted they use such principles to create addictive foods. A New York Times article, “The Extraordinary Science of Addictive Junk Food”, revealed that companies like Frito-Lay use $30 million R&D budgets to hire research staffs of 500+ scientists to create ‘frankenfoods’ like Cheetos. Cheetos include technologies like “vanishing caloric density,” which make them melt in your mouth so quickly “your brain thinks that there’s no calories in it . . . you can just keep eating it forever.” In light of such irresistible foods, why do we actually expect people to exercise self-control and just “stop it”?
All Drugs Aren’t Bad. All Processed Foods Aren’t Either.
In the modern era, we treat addiction as a disease, and often replace addictive and impure street drugs like heroin, with prescription opioid medications like methadone that are purified and better controlled to prevent deadly withdrawals and carefully wean people off. Street drugs and prescription drugs are both “drugs”, but can hardly be equated since the former often takes lives, while the latter can often give it back if properly prescribed and used.
Similarly, we can’t lump all processed foods together as being “bad, m’kay?” Minimally-processed foods like yogurt, butter, and cheese, have been made at home for millennia and also ultra-processed in factories more recently. Studies show dairy consumption is associated with lower risk of type 2 diabetes. The devil is always in the details though, and a ball of handmade mozzarella cheese is hardly the same thing as processed cheese slices that have so little actual cheese in them the FDA requires legally labeling them as “cheese product.”
Intentions Matter: Processing for Health vs. Wealth.
So we should just avoid ultra-processed foods by avoiding all those chemical sounding ingredients we can’t pronounce, right? While this ‘chemophobia’ can be a helpful shortcut, it’s also not always accurate. If you analyze any whole food like a Kiwi, it’s technically made up of a lot of ‘chemicals’ that naturally exist in nature:
Just because a food is ultra-processed or fortified with added ingredients doesn’t inherently make it unhealthy. While the World Health Organization educates mothers that breastfeeding for the first 6 months is the “optimal way of feeding infants”, it also acknowledges that infant formula can play an essential or supplementary role in keeping infants alive and healthy when mothers cannot breastfeed regularly. Thus, some ultra-processed foods are optimized for health more than cost or taste, due to tighter government regulations and more selectivity by consumers.
Processed Foods are not Nutritionally Superior. They are Behaviorally Superior.
So let’s stop idealistically arguing that whole foods are nutritionally superior. Yes, and the real point is processed foods are behaviorally superior in terms of what most people actually eat. Since processed foods are here to stay, we must use incentives, influence, and innovation to get consumers to make better food choices, and also ‘Big Food’ companies to make better processed foods...