The Dr. Hyman Show - Can A Food Product Scoring System Improve Our Diet And Eliminate Nutrition Confusion? with Dr. Dariush Mozaffarian

Episode Date: March 1, 2023

This episode is brought to you by Cozy Earth, InsideTracker, Pendulum, and Pique. When it comes to diet, there's so much changing and conflicting information flying around that it can feel impossible to know where to look for sound advice. Decades of nutritional misguidance, lobbying, and corrupt food policies have only left us more confused when we head to the grocery store. Today on The Doctor’s Farmacy, I talk to Dr. Dariush Mozaffarian about Food Compass, a new food rating system aimed to help determine the general healthfulness of different foods and cut through the confusion when it comes to our food choices.  Dr. Dariush Mozaffarian is a cardiologist, Special Advisor to the Provost, Dean for Policy, and Jean Mayer Professor at the Tufts Friedman School of Nutrition Science and Policy; and Professor of Medicine at Tufts School of Medicine. His work aims to create the science and translation for a food system that is nutritious, equitable, and sustainable. Dr. Mozaffarian has authored more than 500 scientific publications on dietary priorities for obesity, diabetes, and cardiovascular diseases, and on evidence-based policy approaches and innovations to reduce diet-related diseases in the US and globally. He has served in numerous advisory roles, and his work has been featured in a wide array of media outlets. Thomson Reuters has named him as one of the World’s Most Influential Scientific Minds. This episode is brought to you by Cozy Earth, InsideTracker, Pendulum, and Pique. Right now, get 40% off your Cozy Earth sheets. Just head over to cozyearth.com and use code MARK40. InsideTracker is a personalized health and wellness platform like no other. Right now they’re offering my community 20% off at insidetracker.com/drhyman. Pendulum is offering my listeners 20% off their first month of an Akkermansia subscription with code HYMAN. Just head over to Pendulumlife.com to check it out. Right now you can take advantage of Pique’s limited-time special offer on your first month's supply of their Sun Goddess Matcha. Just head over to piquelife.com/farmacy for 15% off plus free shipping on your first month’s supply. Here are more details from our interview (audio version / Apple Subscriber version): Challenges and limitations of nutrition research (5:36 / 3:40) Food rating systems (14:02 / 11:50)  The Food Compass rating system (26:14 / 19:43)  Development and scoring domains of the Food Compass (30:34 / 25:18)  Comparing Food Compass to other scoring systems (39:44 / 34:27)  Research on how following Food Compass would affect health (41:57 / 36:49) Distinguishing a processed vs ultra-processed food (50:25 / 43:26)  Limitations of and areas of controversy with Food Compass (1:00:46 / 55:46) How Food Compass scores cholesterol (1:07:11 / 1:01:54)  Mentioned in this episode 2022 Task Force on Hunger, Nutrition, and Health Report

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a place for conversations that matter. And we're going to get into some deep things that matter to all of us, which is how do we choose the foods we eat? And what is it based on? What are the scientific controversies that exist now around certain things in nutrition? And we have an amazing guest today, someone who's been on the podcast before, who's a good friend of mine, a colleague, and someone who's working in Washington right now aggressively to change overall food policy from food as medicine to regenerative agriculture, and he's in the trenches. He's also a cardiologist. He was the dean of Tufts Friedman School of Nutrition Science and Policy, but stepped down temporarily to actually work on policy in Washington, which is really important. So I think that speaks to who he is. He's

published over 500 scientific publications on diet, nutrition, and I've read many of them, not all of them. He's just so prolific, I can't give up, on obesity, diabetes, heart disease, and how we create evidence-based policy approaches and innovations to get rid of all the diet-related disease we have in the United States and around the world. He's been in lots of advisory roles, and he's been named by Thomson Reuters as one of the world's most influential scientific minds, and he certainly has influenced me in many ways, and I think he's a real icon and leader in the space of nutrition and real change, not just sitting in an ivory tower, but on the ground trying to make real change.

And we're going to talk about some of the things that he's done and some of the things that we need to think about in terms of how we frame our choices about what to eat and how we understand what whole foods are, what ultra processed foods are, how we can evaluate different foods across the spectrum, all the choices we have. And I'm super excited to have Dari back on the podcast. So welcome. Thank you so much, Mark. You laid out why this is such an important topic. We're literally dying from food and we've got to fix it. Yeah, it's true. Now, one of the things that I've learned, and I've written so much about diet and nutrition, and, you know, I've spent 40 years studying nutrition. My first course was at Cornell in, for instance, say 1979. I'm so old. And it was Colin Campbell,

who was a professor of nutrition at Cornell then. And I've been studying ever since. I read Roger Williams' book, Nutrition Against Disease in College. And it really influenced me to think about how we use nutrition in medicine. And as I became a doctor, it became a big focus for me. And I can say after 40 years of this, I'm still freaking confused about a lot of stuff because the way we do research in nutrition is challenging because it's not like you can take 10,000 people, lock them in a laboratory, give them a certain diet, and then take another 10,000 people, lock them in a laboratory, give them a different diet, and study them for 30 years in a laboratory. That would be the way to do it and measure everything.

But we just can't do that. So we have imperfect evidence and we have to make conclusions from those pieces of imperfect evidence. So let's sort of talk to you first about, you know, why people are so confused about nutrition. One day eggs are good, one day eggs are bad, one day, you know, eating carbs are great and we should have six to 11 servings of bread, rice, or pasta, and then we find out they're not so good to have all this rice and pasta and bread. You know, why are we so confused? And what are the limitations of research? How do we know what we know? And going from randomized limitations of research? How do we know what we know? Going from randomized controlled trials to population studies to animal studies to in vitro studies.

Tell us a little bit about how we know what we know in nutrition and how you've come to sort of the conclusions that we can actually start to make choices and decisions about. Right. Great, great question and a good place to start. So first, you know, people are confused and even scientists are confused about some of the evidence because the science is changing. I think that's the first and foremost reason that people are confused because the science of what we thought 30 years ago, it has shifted over time. There have been some real shifts over time. There have been some things that have stayed the same, but there are some things that have changed. And that's for a few reasons. You know, first and foremost, nutrition science is a really, really young science.

From roughly 1932, when vitamin C was the first vitamin ever isolated and synthesized, like that's 90 years ago, the first vitamin ever isolated and synthesized. From 1932 to about 1980, the first kind of 50 years, nutrition science focused on vitamins and focused on calories and getting enough calories. And agricultural policy, food policy focused on those things because that's what the science was. How do we get enough vitamins to people? And just a handful of vitamins, you know, the vitamins that were known, vitamin D, vitamin C and niacin and so on. And how do we get enough calories to feed, you know, a growing world population, a population where more people were born in the last century, about, you know, four and a half new humans were born, more people were born in that century than in all the prior, you know, human civilization, human history combined.

So we had a population explosion. So that's kind of what the science focused on from 1930 to 1980 was vitamins and calories. And it's really starting around the 70s with some early studies, but really starting around 1980 and the first US dietary guidelines focused on chronic diseases in 1980 that we started thinking about in a serious way, nutrition and chronic diseases in 1980, that we started thinking about, in a serious way, nutrition and chronic diseases, complex diseases that take years to develop, heart disease, stroke, atrial fibrillation, diabetes, obesity, cancers, now, and now even more recently, brain health, gut health, autoimmunity, inflammation, autism, you know, many diseases that may be related in some ways to nutrition. And so that's just been 40 years

we've been really studying that seriously. And so the science has changed. Now, I think it's a good question is, has the science changed more or more quickly than other sciences? You know, I'm a cardiologist. And so I think about how cardiology has changed. And the science of cardiology has changed dramatically in 40 years as well. And there's a lot of things that we used to say you couldn't do and, you know, have changed. I'll just give you one example. When I was an intern at Stanford in internal medicine, my first year, we had a patient with heart failure come in with a really rapid heart rate. And I read some studies that said, you know, patients with heart failure might benefit from beta blockers. And I said, that's, you know, really interesting. And I

went to my senior doc and I said, can we try a beta blocker in this patient? And he said, oh, no, no, no. We know very well that, you know, the adrenaline response is needed for compensated heart failure. If we give a patient a beta blocker, they're going to get sick, they're going to die. We shouldn't do that. And then five years later, you know, in the middle of my cardiology fellowship, five years later, several randomized control trials had been published that giving beta blockers to patients with heart failure lowers death, lowers heart attacks. And then, you know, we were writing beta blockers. And my different senior physicians were saying, well, of course, we know that beta blockers, you know, excess adrenergic function is detrimental to the heart. They're backpedaling.

And so that science radically changed. Look at physics. Like physics not only went from Newtonian mechanics to quantum mechanics to general relativity. There's still fights about general relativity and quantum mechanics. They don't work together. Gravity and quantum mechanics don general relativity, there's still fights about general relativity and quantum mechanics. They don't work together. Gravity and quantum mechanics don't work together. And physics is way more simple than biology. Yeah. And over the last 30 years, right, dark energy has been discovered. Dark matter has been discovered. We don't even understand 95% of what's in the universe. And so the science is

really... So if you look at any science genetics physics medicine and nutrition science changes i think what's different to you know get to the crux of your question is that when the science of physics changes or when the science of beta blockers for heart failure change or in the science of chemotherapy for a certain cancer changes you know not most people don't know what had changed. And if they know it changed, it doesn't affect them personally that day. But when the science of nutrition changes, and we go from 1992, you know, food pyramid with, you know, refined grains at the bottom of the food pyramid to today saying, I refined grains aren't good for you.

That's very personal, right? And that really changes daily decisions. And so I think what's different is- Most people aren't trying to figure out whether to take a beta block or not every day. They're trying to figure out what to eat every day, right? Yeah. So I think nutrition science is changing and we have to accept that and accept that we know more. It's better. It's definitely better. But, you know, there are still things we don't know. And there are things that have changed. And we have to kind of say mea culpa, like we were wrong as scientists for what we said 34 years ago.

And I know one of the things you're really focused on, Dari, and I've been part of the conversations and trying to help with this is to try to establish a new National Institute of Nutrition. Most other countries have it. We don't. We spend almost nothing on nutritional science. Like we spend $6 billion on cancer, and we spend billions on Alzheimer's and heart disease, and literally almost nothing on nutrition studies, which are really underlying many of these conditions

or either contribute or are a big cause. So, I mean, it's just, it's really embarrassing. And I know you're working hard to change that and you really kind of moving the needle. So, actually, I was, just as an aside, I was talking to the CEO of Nestle Health Sciences and about Nestle helping to kind of advocate for national instant nutrition. So, we're going to try to push this forward. I think we've got to have it happen because we just have such a lack of really sort of well-funded large trials that are hard to do because it's hard to you know do these randomized trials on people it's hard to kind of control dies it's hard to do it free

we call free living humans who are choices to go oh you give them to eat this but then a night they'll have a pint of ben and jerry's you know it's kind of screws it. So, and then observational studies is where we also try to learn what might correlate, like with smoking and lung cancer, we found there's a big correlation, but it was like a 21 risk as opposed to nutrition studies, which are harder to do. And there's always confounding factors. What are they eating in addition to whatever the bad food is we think is bad? What are they not eating that they need to eat? So it's very complicated. And so we kind of have imperfect evidence. But with that, we still have to make choices. We still have to decide how to guide people on what to eat. We still have to develop dietary guidelines. We have to develop ways to score foods that people and

consumers can use to make their choices and pick better foods. Now, in the perfect world, would we all be eating whole real food that's unprocessed, that's high in nutrients? Yes. But that's not a reality right now in the world because much of the food we eat is processed in some way, is industrial food. And I don't think we're going to get away from that. So in the service of trying to help people, I think Tufts, which is, by the way, the only, as far as I know, the only school of nutrition science and policy in the world, has developed a scoring system that sort of try to improve on old nutrition scoring systems. So around the world, there's ways of scoring foods and whether they're good or bad for you and how good and how bad. But they weren't perfect.

And Tufts spent a lot of time, energy, and money to develop something called the Food Compass, which many of you may have never heard about. But it's an important step in trying to look at food from a more nuanced perspective. And I want to talk to you about why this is so important and also to explain a little bit about the methodology because I think you kind of worked on sort of an algorithmic model of nine different domains of things you're looking at from nutrient ratios to vitamins and minerals to food-based ingredients, additives, the level of processing, the fats that were in there, the fiber, protein, the fats that were in there, the fiber, protein, the phytochemicals, which no one had really looked at before. What's the value

of all these phytochemicals? There were like 54 different things that were kind of looked at. Now, based on that, you kind of developed a scoring system. And I think that, you know, let's sort of talk about, you know, why it's important to do this, what it's used for. Because there's countries, for example, like Latin America, like in Chile, where they put black box warnings or where it says, you know, saturated fat or sugar or calories is bad. And there are limitations to that because not all saturated fats are bad. I don't know if you saw, Dari, the article in the New York Times about this dolphin research with the Navy where they were looking at the C15 saturated fatty acid that's found often in dairy that has enormous beneficial effects for our biology, whereas other saturated fats may not. So I think, I think, let's just sort of kind of have you unpack that a little bit. Yeah, you, you covered all, you know,, you covered a lot of ground. And I think,

you know, let's start with the evidence because that leads into food compass too. I think the way I think about the evidence for nutrition science is because we don't have usually, you know, any single study that can prove something, whether it's a trial or an observational study, it's important to triangulate between different types of studies. And so you want to look at long-term prospect of observational studies of disease outcomes. You want to look at randomized trials that look at risk factors and risk factors for those diseases. So, for example, you might look at a long-term observational study of whether people develop diabetes. And then you look at a randomized trial of glucose or insulin or hemoglobin A1c. And then you hope you can also

get a randomized trial of onset of diabetes, which is harder and more expensive. And then you triangulate and you say, do those three types of studies, you know, show the same directionality and show the same consistent results. And there are some things where we have actually all three of those pieces of evidence. We have randomized trials of disease outcomes, observational studies of disease outcomes, and randomized trials of kind of intermediate risk factors. And probably the best example is kind of the traditional Mediterranean diet. You know, that's been just in all the studies and ever it's been looked at, it's been shown to be, you know, better for health. So I think, you know, even with limited evidence,

there are ways to triangulate. Another example is sugar, sweet beverages, and weight gain. We have all the evidence from all the different types of studies showing that, yeah, you know, sugar, sweet beverages are bad for weight gain. So I think there is, you know, there is consistency for certain things. So food rating. So why would we want to rate foods? So it's not that common in the United States, although there are grocery stores that do it. And so Hannaford's here in New England uses Guiding Stars. Kroger has just launched Opt Up. Walmart had a, I think it was called Great For You or Better For You system. Those are actually all food rating systems.

The government has actually proposed, the Food and Drug Administration has proposed a new kind of definition of healthy, which is a proposed rule, which is actually a food rating system. So that should come out in the United States in the next year or two when the rule is finalized. But while the United States is still, I think, behind other nations, it's it's big time in other other countries. kingdom and australia and new zealand all of them have either mandatory or or voluntary but widely used front of pack food rating systems and they use something called either nutra score or health star rating or the two most common ones and what those systems do is they take seven or eight or nine nutrients like salt and sugar and some vitamins and protein, and sometimes a couple of food ingredients, like the amount of fruits or vegetables, and they kind of put them together in a score to give an overall summary rating to put on the front of package, like health star

rating, you get, you know, a certain number of stars, NutriScore, you get an A, B, C, D, or E. And that is intended to help consumers, you know, make an easier choice rather than trying to look on the back of the pack and, you know, figure out all that nutrient information ingredient. You need a PhD for that. You get a single summary score. And then as you described really well, other countries, especially in Latin America, Chile, Brazil, Mexico, you know, other many other countries, especially in Latin America, Chile, Brazil, Mexico, many other countries are taking a different approach. Their food rating systems just rate single nutrients one at a time. And so if a product has too many calories, it gets a black box warning label, too much sugar, black box warning label, too much salt, too much saturated fat, and even too much total fat in some cases,

get a black box warning label. So all those systems have some pros and cons, but I think they have some significant cons. And so we said, look, can we look at what those systems do and what they do well and add and make them better because they're being used. And they're being used not just for consumer communication, but also for industry targets. And so Nestle globally has announced that they're going to report every year now on their entire portfolio using NutriScore. So they're going to try to improve their portfolio and reformulate their products following NutriScore.

So these food rating systems were kind of a roadmap, a roadmap of where you want consumers to go, where you want industry to go. And a roadmap is, you know, the destination you get to with the roadmap is only as good as the accuracy of the roadmap. And so, you know, NutriScore is pretty good. I don't want to say negative things about NutriScore, but it's not great. It's not great. It has some limitations. And so that's if we're going to go down that road, we're going to improve the food system, but maybe not improve it, you know, in the direction in the direction we want. And so another use of these profiling systems is for investors. Investors are starting to demand metrics for, you know, companies to be doing the right thing, for example, around sustainability and carbon footprints. But increasingly, there's recognition that investors are saying, look, we're also going to demand nutrition metrics. If I want to invest in a big multinational food

company or in a farm or in a supermarket, I want to know, are they improving the public's health? Are they worsening the public's health? And how do you do that without kind of a scoring system? So it can also be used for investors. So there's a lot of uses for these scoring systems. Online grocers is another example. They're not dietary guidelines, right? They're not meant to be dietary guidelines like the U.S. dietary guidelines. They have a different use, right? That's a great point. So let me just give the last example and I'll get that. So online grocers now are trying to decide, like, if I can go to your employer and get your employer to give a wellness benefit for you to buy healthier foods. Right. That, you know, many employers pay twenty, thirty dollars a month for you to have a gym membership.

Right. Employers are starting to say, I'm going to pay twenty, thirty dollars a month to buy healthier foods. If you want to do anything beyond fruits and vegetables, fresh fruits and vegetables, you need a rating system. Like what would the employer pay for and what would they not pay for? You need to have some rating. So that's another use. So there's all these potential uses. You mentioned a really important point, Mark, is that these are not dietary guidelines. And so you're not supposed to use these rating systems to figure out your entire diet. As two examples in Food Compass, asparagus scores 100, which is a perfect score. Raspberries score 100, which is a perfect score.

If you ate a diet of asparagus and raspberries, that's it. You'd get sick. You'd be nutritionally deficient over time. That's not a great diet. And your urine would smell really funny. So what you're supposed to do for these systems is when you're making a choice between usually similar products, if you're in the yogurt aisle and you're looking at this long aisle, if you're in the cereal aisle and you want to buy cereal, if you're in the bread aisle, if you're looking at energy bars in the airport. Yeah, they're not all created equal. the bread aisle, if you're looking at energy bars in the airport, look at all those energy bars, and they're all, you know, all have marketing claims and packaging claims. You know, it's to

help you within whatever your goals are. If you're a vegan, and you're never going to eat red meat or eggs or dairy, but you want to choose healthier grains, it can help you do that. If you're a paleo person, and you're only going to have, you know, focus on paleo diet, it'll help you within your dietary choices. So that's the goal of these rating systems, especially, especially for packaged foods, right? That's really where there's marketing claims and all these other things. And so that's the goal. It's really important. What you just said is super important, Daria.

I just want to highlight it before you go on because, you know, when you go into the store, it's a show, you know, you, you were so confused by all the dietary claims. And most of the, the problems with nutrition labeling has been what Michael Pollan called nutritionism, which is reductionism. And this has led to snack bar cookies, you know, low fat yogurt with tons of sugar and things that are really bad for you. I mean, you know, your Yoplait yogurt, which is sweetened with sugar, is like more sugar. I mean, the Yoplait thing is amazing. You've got like basically a yogurt that you think is healthy for you that has more sugar per ounce than a can of soda. So like that's just kind of out there and you don't have a way of differentiating for the average person. And I do this for a living and I still get like, oh, what am I going to pick? So it's tough. So it has a big value to create this

for consumers. Yeah. I think it's very valuable. And I think you raised an important point, you know, in the ideal world, we'd all grow our food in our own gardens and have our own chickens and livestock and regenerative agriculture, and then cook three hour meals and sit at a table and eat slowly and mindfully like that. That's, and maybe we can get there someday. Maybe that's a goal. But today, you know, today, you know, there are tens of millions of Americans who are food insecure and, and are just struggling to get the next meal on the table. There are billions of people in the world who can't afford a minimal healthy diet with minimally processed foods. We have a faculty member, Will Masters, who's written that, and that's entered the United Nations

scoring, that there's 2 billion people that can't afford a minimal healthy diet. So there's lots and lots of people who need to go into a grocery store, and they are going to buy and need to buy for their time and cost and opportunity processed and packaged foods and so we can't have this sort of privileged view that we should only be eating grass-fed livestock beef from my local farm and organic fruits and vegetables in season and exactly ancient whole grains that that are sprouted with extra virgin olive oil from the right farm in Italy. I mean, it is perfect, but it's a privileged view to say all people have to eat that way and mustn't. So we have to meet people where they are. If someone's going to get breakfast cereal

for their kids, if someone's going to get dessert, if someone's going to go to get ice cream for their kids, which is totally fine. If someone's going to get dessert, if someone's going to go to get ice cream for their kids, which is totally fine. If someone's going to get candy for Halloween, can we help people make a healthier choice? So that's the goal of these kind of integrating systems. I think it's really helpful. And I think what's different from my perspective about the food compass system is that it tries to not be so reductionist. It's still reductionist to a point, but it looks at, you know, 54 different determinants, not just salt, sugar, saturated fat, calories, which is kind of what most of the

rating systems are relying on. And they're looking at more of the sort of complex mixtures of foods and, you know, complex products that are more than one thing, you know, like, and there's still limitations, like there's, there's no knowns, right? We know that refined sugars and flours are bad. There are kind of things that we know that we really maybe weren't able to sort of include in the calculations because there's no data, like what's the glycemic index or load of foods and when you eat it and what's your microbiome and what's your insulin resistance status and how does it affect you, right? Because the same food can affect this different people in very different ways, depending on your own unique metabolism and biochemistry and microbiome and genetics, right?

So none of that, you know, we can really know well right now. Maybe at some point in the future we can. And then there's things we don't know. Like we just don't know we don't know, which are kind of, for example, like phytochemicals. We didn't even know there were phytochemicals that were important. They were called secondary compounds that were not important, but turned out, I think, maybe to be the most important things in the food we're eating. So doing this is an iterative process.

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Yeah, no, you, you, you gave a perfect summary of kind of our approach. And so first this is research. This is science. We're trying to build a better mousetrap and it's iterative. And what we've done is developed the system and published two papers on it. And now based on just two papers and that work, we're improving the system further. And so what we did is first get a group of great diverse scientists together, economists, people who study global nutrition, people who study phenolics and phytochemicals, epidemiology, physicians, you know, a great group of scientists together and to just sit down and say, what are the things that we think are the top scientific principles for rating foods? And we want to move beyond,

you know, fat and calories and saturated fat and sugar as the and salt as the top determinants which are basically the top determinants in NutriScore and Health Star rating there's some other things but those are the top and by the way Dari that's what leads to food companies being able to sort of manipulate foods and tile up or down ingredients to create junk food that looks a little bit better but isn't like snack roll cookies that was a great example right right and And we also consciously wanted to say, whatever we create, we want it to be, you know, not be able to be gamed by the food industry, right? You really have to make the food healthier. So, so we ended up creating a more

holistic system. It's more complicated, but it's more holistic. And so it has nine kind of areas or domains that are all rated first. And then those, those domains are, are, are, are some, and that domain approach is really important because it means that like, even if it's terrific and amazing in one domain, but it's really bad in the other eight, it's going to get a bad score. And so that means, you know, food has to holistically be good across multiple things or to get a good score and holistically be bad across the things to get a bad score. And if it's in between and a mix, it gets a middle score. Rightistically be bad across the things to get a bad score. And if it's in between and a mix, it gets a middle score, right? So if you put all these phytochemicals in Coca-Cola,

it doesn't make Coca-Cola good, right? That's right. It's not going to change the score very much. And so the different domains included things like vitamins and minerals, which makes sense, but also food ingredients. We had a lot of data on food ingredients. We included processing. So this is the first time that- But food ingredients, talk about the food ingredients. Go a little deeper, because I think the food ingredients was interesting. You have food-based ingredients, additives. What are the things you looked at? Well, let me go through the domains and then maybe touch on the specifics. But yeah, so processing was included. And so things like the NOVA classification of ultra-processed foods, we included additives, additives like not only added sugar and salt, but we think we should score artificial sweeteners, artificial colors, other things. shouldn't get dinged because it has calories. Like that, that doesn't make any sense. We didn't include total fat. Total fat is not useful for health. And we didn't include saturated

fat by itself. No, no food gets a negative point just for having saturated fat. We included the ratio of, of unsaturated fats to saturated fats. And so, and we included phenolics, you know, flavonols, carotenoids, we included trace lipids, things like omega-3s and trans fats and other things. And so overall, about, like you said, 50 attributes across nine domains. And then we combine that into a linear score that rates every food from 1 to 100. And a food that gets a 50 versus a 55 isn't that different, right? Like you don't want to be micro micro judging food. So we roughly said, you know, foods roughly they get a 70 or above are probably pretty healthy and are foods to be encouraged based on our findings.

Foods that get, you know, 30 or below are foods to be minimized, not never eaten, but minimized. You know, those are things you probably don't want to eat a lot of. And then foods kind of in between 30 to 60 are foods to be eaten in moderation. And of course, probably higher scores a little bit better than lower scores, but roughly foods in that middle range to be eaten in moderation. And so that's kind of the overall scoring system. And then once you make the scoring, right, then you apply it. So first, and I think this is really important. The other thing you did was the ratios, which was, I think, interesting. Oh, yeah.

Like when you looked at nutrient ratios, which I think is something that people don't understand, like fiber and carbohydrates or sodium and potassium or the amount of unsaturated fats, the saturated fats and omega-3s. So you had a, is it more nuanced to kind of look at everything? Yeah. So actually, the single most predictive, because we looked at how the domains predict healthfulness in people in a second paper, which we can talk about. But of the nine domains, if you look at the nine domains separately, one of the most important predictive domains for the healthfulness of the food was this ratio domain, which just included three ratios, ratio of unsaturated to saturated fat, which gives a rough measure of overall fat quality, the ratio of carbohydrate to fiber, which gives a rough measure of overall carb quality, and the ratio of sodium to potassium, which gives a rough overall

measure of mineral quality. The reason the carb to fiber ratio is important, Mark, is because if you just look at sugar, you're going to miss refined starch. And so one of the big, big to me, you know, missing holes of the current systems is there's no negative scoring for refined starch. And so if you get a cereal or a cracker or an energy bar or white bread, that's just 100 percent starch. You and I know starch is glucose. Starch is 100 percent glucose. The test, you know, the test standard for glycemic index is white bread. Right.

Glycemic index of 100 is white bread. It's the worst. Right. And so that's the test standard for white bread. For glycemic index, 100 is quite red. It's the worst, right? And so that's the test. It's worse than sugar, right? For glycemic index, it's worse than sugar. So we really wanted to give negative points to refined starch and not let starchy products, refined processed starchy products, grains get a free pass. So that ratio domain was very important. And, you know, the sodium to potassium one is also, I think, important because we know salt raises blood pressure. We know salt is bad. I mean, there are some salt skeptics,

but it's been clearly documented, including in randomized trials of stroke risk. But potassium counters that. Potassium counters that. And so if you have a product that has 300 milligrams of salt, sodium, 300 milligrams of sodium and 10 milligrams of potassium, it shouldn't get the same score as a product that is 500 milligrams of potassium and potatoes are kind of a good example potatoes have a lot of starch but they also have potassium and so you should credit that potassium so so so the you know we could go into all the details of all the domains but but um you know we really tried to be careful and holistic and what i want emphasize too, is we didn't look at the products and say, how should this product score? Let's score it.

We created the system and then said, okay, now that we've created it, let's see how it scores on actual foods. And let's see how it compares to other nutrient systems that are food rating systems that are out there. And let's see if it predicts health outcomes that people actually, you know, followed the system. So that's science, right? We didn't prejudge or pre-guess what would happen. We set up the system, we published our paper transparently, we published the whole algorithm transparently so people could look at it and give us feedback. Yeah, I mean, it's super helpful. And I think it's a big advance. And there's still a lot to do and a lot to learn. And I think, you know, as I was going through it, I mean, there are people have, you know,

pushed back on some things, the things that, that caught my attention were things that, you know, from a, I would say I'm maybe more of a nutrition purist, but I felt like what's optimal for humans, right? Is how, how do we look at, for example, like the quality of fat. So you have an unsaturated to saturated fat ratio, but what is the unsaturated fat? Is it omega-3s? Is it maybe more beneficial seed and bean oils like canola and soy, or maybe ones that maybe have shown to be more harmful like corn or peanut? So there's little things like that. And then cholesterol was the other thing I was wondering about why that was included because of the sort of newer data that show that it doesn't seem to have a huge impact on cardiovascular disease. So there were just things that were interesting. And then I think

there's also, you know, we talked about this earlier, was that there's not a lot of good databases on the glycemic load or index of food. And that, by the way, is variable depending on the person. So that's hard to include in something like this, which I think you try to do with the carbohydrate fiber ratio, but there are all these challenges in the research. So it's clearly some stuff we have to try to figure out how to kind of layer on top in some way or refine, or when there's more data come in to kind of update it. Yeah. And so, well, so first, what did we find? I mean, we should, you know, once we did it, so we published two papers. In the first paper, we compared Food Compass to other food rating systems, particularly Nutri-Score and Health Star rating,

which are, again, pretty good. They're not terrible, but pretty good systems used around the world. And we found on average it works better, right? On average it works better, right? On average, it works better. That in particular, our scoring system gives really low scores to refined grain products, even without added sugars. And in those scoring systems, refined grain products that don't have added sugars get great scores. And you think about kind of a Corn Flakes, you know, a non-branded Corn Flakes cereal, it's just corn, corn starcharch, not corn. It's just cornstarch.

It's 100% glucose. It's glucose in a box, but it doesn't have added sugar. It doesn't have a lot of fat. It doesn't have a lot of salt. It gets great scores on Nutri-Score and Health Star rating. In Food Compass, it gets one of the worst scores because it's refined starch. White bread, pita bread, bagels get very low scores. Low- uh deli meats low fat processed meats like bologna got good scores on those systems they're low fat right they got credit for being low fat they get terrible scores on our system low fat coffee creamers low fat salad dressings all these low fat products got low scores on our system because they're processed and um have a lot of starch in them so so overall it worked better than the other systems.

And I should, of course, mention, since we didn't give negative points to total fat, and we gave positive points to unsaturated fat, nuts and seeds and oils scored really well. And so one of the big criticisms of Nutri-Score, for example, is olive oil. Extra virgin olive oil scores really terribly, and nuts and seeds don't score that well. And there's been olive oil growers in Europe have actually sent letters and gotten angry and said, why are you telling us extra virgin olive oil is an unhealthy food? Those foods score like over 90 on Food Compass, right? So extra virgin olive oil, I think scores over 90, nuts and seeds score over 90. Most seafood score really, really well because they have omega-3s.

We did account for omega-3s, Mark. So seafood- Yeah, although most processed foods don't have olive oil in it, right? That's true. That's true. Yeah. So those are the positive things. And then in our second paper, so it worked better than Nutri-Score and Hill Start rating, we think. Our second paper then, I think we did something really important. We said, okay, that's just the ratings, but what if somebody actually followed it? How would it affect their health? And so we looked at a nationally representative sample of almost 50,000 Americans who had been followed for many years and who had all reported what they'd eaten down to the product level, very specific products of what they had eaten.

And we scored all the foods they had eaten. And we gave each person an energy weighted food compass score. So, you know, based on the food compass scores and the calories of all the items you ate, what's your energy weighted food compass score? And we looked at how that predicts health outcomes. And we found on average for, again, food compass goes from one to 100. We found on average for every roughly 10 point difference in the individual's food compass score, they had lower obesity, lower hemoglobin A1c, lower fasting glucose, lower triglycerides, higher HDL, lower systolic blood pressure, lower diastolic blood pressure, lower LDL cholesterol. When we looked at diseases, they had lower systolic blood pressure, lower diastolic blood pressure, lower LDL cholesterol. When we looked at diseases, they had lower risk of metabolic syndrome, lower risk of

cardiovascular disease, lower risk of cancer. And when we looked at mortality, all-cause mortality, for every 10 points, roughly, in the Food Compass score, they had a 7% lower risk of dying. And so that is a very strong validation that on average, across thousands and thousands of products, the food compass works well. It has areas for improvement, which we can talk about, but on average, it works well and it predicts better health outcomes. Well, I just want to highlight that because I think what you said is very important. We can get into the ways to improve it and the challenges. I think the fact that people are

criticizing it ignores the outcome data you just talked about, which is that when you look at what actually happens to people who follow this, and you can kind of reverse engineer who ate what foods through these studies, the large national databases, they lowered all their cardiovascular biomarkers. They lowered their risk of diseases, like you mentioned, heart disease and blood pressure issues and diabetes and death. So, you know, while it may not be as good as if you took a, you know, like I said, a regeneratively raised grass-fed this and organic that and only completely unprocessed food, it's a hell of a lot better than what the average Americans are doing.

So it's sort of a guidepost to go from terrible to better to even better. That's right. Yeah, that's exactly right. So I wanted to sort of also sort of highlight that just what you said, which is that many of these scoring systems don't address the problem of refined grains.

Our friend David Littwick says, below the neck, you don't address the problem with refined grains. Because, you know, our friend David Littwick says, you know, below the neck, you can't tell the difference between, you know, a bowl of, you know, cornflakes and a bowl of sugar and the body, whether they're refined processed grains. And I think that that's an important point that the food compass does score for, which is the refined grains and the harmfulness of them. And I think it's really pretty important. So I am really glad that you've done that. And I think that that speaks to, you know, the changing science about how we actually

need to think about processed starch, which is more or less like sugar. I call it the hidden sugar. Yeah. Yeah. Um, so, so let's kind of dive into, you know, um, some of some of the controversies in nutrition a little bit more in general. Before we do that, Mark, though, I'd love to talk actually about where Food Compass itself, before we talk about controversies, didn't work so well and where there were some controversies about Food Compass. Because there was social media and other things that picked out some products and said why they score this way so i think it's good to cover those if i can so so so um so you know um we scored in our first paper

8 000 products in our second paper almost 60 000 products and again on average it works really well but if you look across all the products, especially if you compare across food categories, you see some things that look funny. If you compare within a category, if you compare within breads or within energy bars or within cereals or within meats, it kind of always makes sense. But when you start comparing across categories, you know, some things kind of jumped out and were highlighted on social media and led people to, you know question food whether food compass works well and the most the generally the thing that was most noticed was that um you know certain processed foods that had whole grains but were processed and had also might have some sugars tended to

score kind of in the middle like a score of 50 or 60, and then minimally processed animal products, certain cheeses and red meats in particular scored a little bit lower, still in the eat in moderation range, but scored like 40. So why is it that processed whole grain cereals score higher than minimally processed animal foods? And so it's worth unpacking that a little bit. And so first, you know, eggs and poultry. Before you explain, I just want to point out that red meat, eggs, and poultry all scored higher than the refined grain products like bagels, breads, crackers, cornflakes, and different cereals. So I think people will kind of miss that point. I think it's not like all those animal products got scored terrible and they were variable.

Yeah, there was a huge range of how cheeses were scored and eggs were scored and meats were scored, depending on what you ate with them, how you cooked it and so on. But I think that's a really important point. Nobody put out a chart like showing the thousands of processed cereal products and breads and crackers and energy bars that scored way lower than red meats and eggs and poultry. Right. They pointed out the processed whole grain products that tended to score higher. And some of those whole grain products had no added sugar. Some had added sugar. Some of them were mostly whole grain. Whole grain was the first ingredient, but they also had added sugar.

So I think that's a really interesting question, which gets to where do you score, how do you score minimally processed animal foods to where do you score? How do you score minimally processed animal foods? Where do those fit? Which is kind of one of these controversies in a healthy diet. And how do you score processed whole grains, right? We know we're supposed to eat more whole grains, but if the whole grain has been finely milled and spit out in the form of a cereal or, you know, even whole grain bread in the United States, usually the components of a cereal or you know even whole grain bread in the united states usually the components of the whole grain have been separated extracted and then mixed back together in a factory it's not like they took a whole grain and milled it it's not like a german rye bread you have to cut with a meat slice a meat grinder i mean those like like deli meat so i think those

are valid break your knife i think those are valid questions is does food compass score whole grains that are processed a little too highly? They're still better than refined grains, but but should they be maybe scored a little bit lower and and should minimally processed eggs and red meat in particular poultry and seafoods score and dairy foods generally score quite well. Should should those foods score a little bit better? And so we're looking at that question and looking at scientifically, you know, some of the scoring makes sense. And I think we've, over the last year, since, you know, science takes time, we've been working on this. And I think we've actually come up with some really good solutions and we're validating it now to make sure, as we discussed, like if you look at Americans and health outcomes, does this system work better than the original system?

So I think our next system is going to work even better. But I think it is an interesting open question, which we can talk about now, is for sure a processed whole grain cereal, even with sugar, is better than a totally refined grain cereal. And for sure, a minimally processed whole grain that hasn't been processed at all, like, you know, or minimally processed like silica oats is better than a processed whole grain cereal. That's we all we're all but is a processed whole grain cereal healthy? Or is it not healthy? Because it's processed, it's whole grain and it's processed. Like, what wins that battle of healthiness? It depends, right?

It depends on what else is in it, right? How many additives, how many colors, how much extra sugar, what kinds of sugar. I mean, there's so many variables you can take. I've seen the food companies do that. I mean, whole grain, you know, like Cocoa Puffs or something. And I'm like, well, I don't know if that's a good idea.

You know, and I think the real question is, what is an ultra processed food? What is a processed food? Was it a mentally processed food? I don't think people make the distinction. And I've even talked to food industry experts that go, oh, you say ultra processed food, but what is that? And maybe it's not this, maybe it's not that. So could you kind of talk about the definition of what that is and how you distinguish from an ultra processed versus a mentally processed food? Yeah. So there's no kind of single widely totally accepted definition. But the but the most widely accepted and used definition comes from Carlos Montero, a good friend and colleague in Brazil, his group.

It's called the Nova classification. And we actually worked with him. We shared a doctoral student who came and visited me in Boston, and we worked together on some of the earlier papers he did. And I even gave a little bit of feedback to the system, which I think, you know, might have tweaked it and made it even a little bit better in its early stages. So I like the NOVA system for classifying foods. And it basically classifies foods from NOVA 1 to NOVA 4. NOVA 1 is basically unprocessed foods, fresh fruits, fresh vegetables, fresh nuts and seeds, things like that. Eggs, chicken, unprocessed foods. NOVA 2 is culinary ingredients. So oils, flours, sugar, things that you might cook with if you're actually cooking at home, baking at home.

Nova three is processed foods, which which have a little bit of processing, like canned tuna or cheese are considered processed foods. Cheese has the salt for preservation and canned tuna has the salt in it. And then ultra-processed foods are foods that are made by industry, have multiple ingredients beyond just kind of like maybe just a little bit of salt for preservation. Yeah, like canned tomatoes or whatever. Well, canned tomatoes would be – NOVA 3 would be processed. That's what I mean. It's like processed, but it's but you still know what it is. And so what Carlos has shown in his research and we've shown in our research too is that on average, if you eat more ultra-processed foods, you have a really bad diet, you have worse health outcomes. And if you eat less ultra-processed foods, you have a better diet, healthier diet, and you have better health outcomes. And interestingly, processed foods, that NOVA 3 category, look a lot more like minimally processed foods and ultra-processed foods.

And so having a little bit of processing seems to be fine. So again, canned vegetables, canned tomatoes, canned seafood seem to be pretty healthy, actually. It's really these ultra- Sour crowd, pickles, those are processed foods, right? So the remaining question, though, is, okay, those are processed foods, right? So, so what's, what's the remaining question though, is okay. Now that we know this, like, what does it mean? Because ultra processed foods are more than half of the calories in the United States.

And 67% of kids diets. Yeah. And we've published that, that some of those papers. And so if you go to the grocery store, also's a big difference in in the amount the the healthfulness of ultra processed foods in my book right like if you get a totally 100 whole grain cereal with no very few additives that's process ultra processed versus a super refined starch refined grain sugary cereal the whole grain one is better for sure right or energy bars like this is, me in airports, like you and I travel, you can get an energy bar that's mostly unprocessed nuts with a little bit of honey and added sugar, right? Or you can get an energy

bar that's like all refined grains. There's a big difference. Or, you know, a frozen dinner or a pizza, you could go on and on down the list. So I think that the NOVA classification is great, and it is what we used as one component of Food Compass. But by itself, we still have to help consumers choose between ultra-processed foods, right? There's going to be a gradient within ultra-processed foods. And I think that second question, then just a scientific question to ask Mark is, okay, we know we need to have some processing of food to have them be shelf stable and cheap and shipped around the world and convenient. What is it about the ultra processing that's harmful? And how do we fix it? Right.

How do we fix it so that we can have processed foods that are actually better for us? And we can talk about that if we have time. I mean, I'm even confused, Ari, about what an ultra-processed food is. I mean, if you take like a whole grain and you pulverize it, so it's flour, and then you reconstitute it and add a bunch of vitamins and sugar, is that an ultra-processed food or is that a minimally processed food? mean it's a if you do it at home it's it's minimally processed but if a baker does the exact same thing in the bakery and puts it in a package it's ultra processed so so even who makes it changes the definition according to the classes so by that definition they're all like cereals

cereals like our breakfast cereals. Are those ultra-processed food? I think pretty much all breakfast cereals would be ultra-processed, with the exception of, let's say, if you buy a Bob's Red Mill. I think we have it in our pantry. Bob's Red Mill steel-cut oats that you cook. Pretty much anything in a box, a package that's like got the wrap, right? That's almost all going to be ultra processed. And of course, there's a big

range. I grew up on cream of wheat. I love that stuff. Yeah. The little instant oatmeal packet, right? The little instant oatmeal packet that you shake and you put in the microwave, even if it's plain, it has some preservatives. It has a little bit of salt as that's ultra processed by the definition. But you know, is that the worst thing you could eat it's probably not perfect but it's probably better than other choices so i think i'll i think the processing classification is good but we have to figure out what's what's harmful and and you and i can talk talk i know you and i've talked about this personally but i can just quickly summarize what i think is where the science is taking us to fixing processing. I think that there's basically a couple of things that processing does that makes the food particularly harmful and a couple of things that processing does that takes out things that are good.

And that combination is what causes the harm. Ultra processing often takes out is fiber, fiber is prebiotics for our gut bacteria. And all of the hundreds of thousands of phenolics and flavanols and bioactives and other nutrients that you were talking about, which I think those two things, fiber and phenolics are two of the most important things in the food supply for health. And so ultra processing- I think that is so important. Yeah. What you just said, we should stop there.

Stop there for a second. That's a very important statement, that the amount of fiber, which comes from beans, grains, vegetables, fruits, nuts, and seeds, that's hugely important for our microbiome, which determines everything about our health. And secondly, the 25,000 or who knows how many phytochemicals that are- 1.5 million. 1.5 million now.

Oh, geez. I'm off. I'm off now. I'm off. Oh, I'm screwed up with my numbers. Last I looked, it was 25,000. So, okay, a million, maybe it's going to be 10 million, who knows, but there's shit we haven't even discovered yet. And these compounds are the medicines in food that regulate so much of our biochemistry, our gene expression, our longevity, our brain chemistry. I mean, it's really quite remarkable how these things work. I mean, I just, I'm going to send you my book on Young Forever, but I was just so shocked to learn about how many of these phytochemicals regulate so many of these longevity pathways

and nutrient sensing systems and so many different things that are so critical for our health. So you're right. Taking those out are so important. Yeah. It's what's in cocoa. It's what's in green tea. It's what's in coffee beans. It's what's in nuts and seeds, right? It's these hundreds of thousands of compounds. So I think ultra-processors generally take those out. And then I think the beyond and then they add things. So they add added sugar and salt. And for sure, we know that's bad. But I think beyond added sugar and salt and I think and beyond phenolics and fiber missing,

I think that people have thought about those four things. I think the fifth and maybe most central harm is what I call acellular nutrition and what others have called acellular nutrition. The intact food structure has been totally destroyed. And so any food we eat, plant or animal, has some intact cellular structure. And when we eat that, the intact cellular structure changes how quickly and where in our digestive system the food is digested. And so if you eat steel cut oats, for example, steel cut oats have some intact food structure. It gets slowly digested all the way through the GI tract so that by the time it even gets to your large gut, there's still some intact starch and sugar and food in there and your gut bacteria digest that.

They're healthy. They're happy. They're like, wow, we got silk cutouts for breakfast, right? But if you have a finely milled, highly processed whole grain, it has the fiber. It might even have some of the phenolics, but it's digested very rapidly because it's acellular. The cellular structure has been destroyed. And so I think acellular carbs in particular are negative. And I think acellular proteins are negative we can we can talk about this mark, but if you have protein, and you're not working out in the gym building muscle, if you have protein and protein gets into amino acids get into your bloodstream from eating processed protein, or the extra cup of protein powder in your shake or protein bar, or these plant based, you know, meat alternatives that have ultra processed protein in them. If you're not pumping iron,

that gets turned into fat by your liver. That all goes to fat. And so it causes insulin resistance. There's been trials showing that high-protein diets, if you're not exercising, cause insulin resistance. So I think acellular carbs, for sure, and maybe acellular proteins are some of the worst things in the supply. And so what all that means is a food companies can invest in and

understand how to make all the processed foods that we like to eat, but keep the fiber, keep the phenolics, don't add as much sugar and salt and keep the food structure intact, more intact, right? We'd have a healthier food system. Yeah. I mean, I think you're right. And I think one of the one of the things I want to sort of unpack here is I think, and I think is some of the reason for the pushback is that some ultra processed foods were scored high in food compass. And, and I think, you know, we talked about this, but one of the one of the challenges is the things that was for me was missing, but it

was sort of approximated with a carbohydrate fiber ratio, fiber ratio was the impact of different foods on insulin secretion, glucose, and which to me is one of the biggest drivers of chronic disease and aging in this country. So absent that in the thing, you get high scores for orange juice, which I wouldn't highly recommend, or some of these processed cereals, which may be whole grain and they get a good score for that and they don't have a ton of sugar, but is that really a good idea? So what's the glycemic load of some of these cereals when you take them alone or even if you have them in milk? So I think I just have this in my head that people are pushing back because there wasn't an ability to use this

framework of how these foods impact blood sugar directly or insulin. Can you speak to that? Yeah. Well, so first, the vast majority of feedback we've gotten on Food Compass has been very, very positive. And so we've had researchers from other countries around the world actually contact us, say, we see these other food rating systems, Food Compass is much, much better. Can you work with us to create a Food Compass for our nation? We've had people working in healthcare centers and healthcare clinics, working with low-income populations who say, we want to give a simple guide to our patients to help them eat better. We really like Food Compass. We've had nonprofit organizations, app developers, employer wellness companies,

lots of people who actually read the papers in detail and say, this is great and like to use it. So I don't want to overemphasize that there's been pushback. Where the pushback has been is if you just take 10 or 20 of the products- I was just reading some of my concerns as I read it, even just my thinking about it. Valid, very valid. So I think the questions you're raising are very good, open scientific questions that I think we should have some real honest scientific debate about. The number one source of whole grains in the United States is breakfast cereals. Right. That's the top source where Americans are getting their whole grains. And many food companies have actually done that through stealth. They haven't said it. They haven't told us. They've changed all these processed cereal products to be almost entirely whole grain.

They put it on the front of the package. They're not shy about advertising. It's not been done like, you know, they're not advertised as whole grain cereals, right? Some of them because they have sugar and other things in them. Most Americans don't know, I'll put it that way, that they have whole grains in them. So I think that's an open question is what is the impact of that on health? And I think, you know, the way I look at it is they're definitely better than the refined grain version, the original refined grain version.

So that's an improvement. They're definitely worse than a minimally processed whole grain that you might like, you know, again, get steel cut oats and cook it overnight and eat it in the morning. But I think it's an open question is how healthy are they by themselves? And, you know, you and I kind of looked at this over the last week and shared shared some studies back and forth. Overall, randomized trials in people show that if you give people more whole grains in place of refined grains, you lower insulin, you lower hemoglobin A1C, you lower glucose, you lower triglycerides. And so you improve metabolic health. Most of those trials use minimally processed whole grains. So it doesn't answer this particular question yeah exactly right there have been two trials which which we kind of looked at together they're not great but there have been two trials one funded by food industry that have looked at refined whole grains yeah it's not refined whole grain that's the wrong word

processed whole grains um uh you can't have a refined whole grain. They've looked at processed whole grain. Just to be clear for listeners, a refined grain is you've taken out the bran, you've taken out the germ, and all that's left is the starch. That's a refined grain. So refined grain is starch. Yeah, there's no oil, there's no fiber, there's no minerals, there's no vitamins. It's just starch. And starch is glucose. Starch is 100% 100 glucose so cornstarch rice starch wheat wheat flour multigrain it's refined grain right so so a whole grain is you have the bran the germ and the end of sperm but it could be might be processed it might be finely milled and processed so so i should say let me just go back process whole grains so they're having these two trials with

process whole grains and both of them in patients with diabetes also actually showed some benefit compared to refined grains. So that's one piece of evidence. And then secondly, we have observational studies. We have multiple long-term observational studies which have their limitations. But in those long-term observational studies, the majority of the whole grain consumed is processed whole grain. It's processed wheat bread, processed crackers, processed pasta, processed cereals. And in observational studies, people who eat more processed whole grains have lower obesity, lower risk of diabetes, lower risk of heart attacks, lower risk of stroke, lower risk of certain cancers. So if you take the limited trials we

have, not much, and the long-term observational studies we have, my gut sense, no pun intended, is that compared to the current pretty bad American diet... Microbiome intuition. Yeah, microbiome intuition. Compared to the pretty bad American diet, processed whole grains are a good choice to them, right? Compared to the ideal diet, they're probably not a good choice. But compared to the current American diet, I think they're a good choice today. Yeah, I agree. I think, you know, it's always like my sister's telling me this joke,

you know, the Vermont farmer gets asked, how's your wife? And he goes, compared to what? You know, and I think if we're, what are we comparing it to? And I think it's compared to the traditional standard American diet, the sad diet, clearly adding whole grains in any form is, is an improvement. It's really about, but it's really about the total complex mixture of your, of your diet. And that's why sort of the kind of parsing these individual ingredients is problematic. When you include, you know, 54, it gets a lot better than just doing three or four.

And so that's really the attempt to try to keep improving. And I think you're going to learn a lot more. I think there needs to be some tweaks in it. I mean, one of the things I noticed was that cholesterol was used in there as a metric. I don't know if that was a ding or a negative or a positive, but I think it was a ding on the score. And I think I wondered why that was included because the new kind of dietary guidelines recommendations that it's not a nutrient of concern and that it doesn't really dramatically impact blood lipids, even though it sounds like cholesterol in your blood, cholesterol in your food, it's confusing. So can you just kind of talk about that? Sure. Yeah. So we have one domain where we're called

trace lipids. And so in that domain domain where we were called trace lipids. And so in that domain, we want to include trace fatty acids, which at small levels have trace fats, trace, trace lipids that that at small amounts have important biologic effects. And so there we have seafood based omega three is like EPA and DHA. We have plant based omega3s like ALA. We have industrially produced trans fatty acids, which aren't that common in the United States anymore, but are present in other countries. I think we have, I think we wanted to, I have to go back and look now. I think we have branch chain fatty acids was a concept. I don't know if we were able to get measurements on that. That was a concept to put in there.

Medium-chain triglycerides was another concept we thought about putting in there. But we didn't decide to include cholesterol in there. And the reasons for that is reviewing all the science. The 2015 Dietary Guidelines said cholesterol is no longer a nutrient of concern for overconsumption in the United States because the average cholesterol consumption in the United States because the average cholesterol consumption in the United States is about 200 milligrams per day. The recommended maximum is 300. Very few Americans are consuming over 300. So they said it's no longer a nutrient of concern. That doesn't mean it's not biologically relevant and it doesn't do anything. And I've reviewed all the evidence up to 300 milligrams a day. Cholesterol probably doesn't

have, you know, a big, a big impact over 300 milligrams per day, 400, 500 milligrams per day, which again is not common in our country, but in other countries still you sometimes see it does start to raise bad cholesterol. It is associated with, with harm. And interestingly, dietary cholesterol at current levels in the United States is associated with diabetes, not heart disease, diabetes, observationally. People who eat more cholesterol have high risk of diabetes. I don't know why. It's observational. It may be confounded. So we decided, you know, with that kind of mixed evidence, we should include cholesterol, but it's one component of five in one domain. And so if a product like eggs, for example, have a high

cholesterol, at most, it might reduce its food compass score by a point or two, right? It's not going to reduce the points by five or 10 points. And I think a boiled egg, I can't remember in our paper, but I think a boiled egg gets a score of like 55 or 60, you know, food to eat in moderation, kind of the upper end of a food to eat in moderation, even with cholesterol, it doesn't get a bad score. So I think it's a valid question. Egg whites, right? Again, I get a worse score than egg whites, right? I mean, it isn't if I had to choose. And I think it gets a worse score than egg whites, probably because of the fat ratio more than the, more than the, more than the cholesterol. I don't, the cholesterol probably has a tiny, tiny back,

but I think it's a fair question. Like you could say, you know, and that was the consensus of, of, you know, of the scientific team that put it together. Yeah. But it's a fair, you, we could have created it without cholesterol and, and I think it probably would have worked almost exactly the same. Yeah. Yeah. Fair enough. You know, I think for everybody listening, you can get, there's a lot here to dive into and we literally are scratching the surface. And I think Daria and I could talk for days and weeks about all these topics and the fine points of nutrition from, from sugars and processed foods to oils to meat and all the data on it. And maybe we'll have them back for another podcast. I think doing what you do is not easy trying to go through the mounds of data. And sometimes it's junk in junk out. Sometimes there's better studies.

It's just, it's, it's hard to make sense of. And I think, you know, you, you are one of the, I think in my, my opinion, one of the most prolific and also most thoughtful and balanced scientists out there in the field of nutrition. So I thank you for your tireless work and your constant good humor. I don't know how you do it, but you do. And we'll get more to these topics later because I think we have a lot more to unpack as we go forward in this world of nutrition and how to make the world a healthier place. I appreciate the conversation and thanks for all of the work you've been doing to promote kind of better understanding of nutrition.

And I will say, Mark, that we absolutely need to radically reinvent the food system. The food system is broken. It's making us sick. It's causing health inequity. It's crushing our healthcare system and our economy. So we have to radically reinvent the food system

and we can do it. We can actually do it. We can do it with technology and figuring it out in science. We need some investments and, and to figure it out, but we can do it. And while we're doing it, we need to help people eat better with what we have today. Like, so, so it's not a either or we have to do it all, but you know, we're, we're not happy with the current food system, but we have to help people make better choices and navigate within it. We have to and we have to radically reinvent the food system at the same time. And we've published policy papers on this. Hopefully we can link to it in your podcast, some of our task force report for the White House.

There's a whole bunch of things that can that are very doable, very sensible that we can do to fix the food system. So look forward to getting there and to feeling young and healthier longer for all of us. Absolutely. And just kind of reminds me of that saying, don't let the perfect be the enemy of the good. I think we're not perfect, but we're getting better. So thank you, Dari, for your work. And I look forward to working with you more in DC. If you love this podcast, please share with your friends and family on social media, leave a comment. What have you learned? What do you think is good and not good? How have you found these ideas helpful for you? And subscribe wherever you get your podcasts, and we'll see you next week on The Doctor's Pharmacy. If you like this conversation, I know you'll love my new book, Young Forever. If you pre-order this

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