Like multitudes of others, I sucked down a recent New York Magazine Q&A irresistibly headlined "The Last Conversation You'll Ever Need To Have About Eating Right." It came close to living up to its billing, but it left me (sorry) hungry for more.
So I turned to Dr. Dariush Mozaffarian, dean of the Friedman School of Nutrition Science and Policy at Tufts University. Our exchange, edited:
First, the big picture: What's at stake here?
Right now, food is causing more deaths and disability in the United States than any other factor, including tobacco smoking. We really have a national — and really global — nutrition crisis. So for example, by our estimate, poor eating is leading to nearly a thousand deaths per day from cardiovascular diseases, obesity and diabetes. So this is really a challenge we have to face.
Do you ever feel like the women in the 'Women's March' carrying signs saying 'I can't believe I still have to carry this sign?' Or has the science been advancing fast enough that in fact it makes sense to keep revisiting how to eat well?
I've been interested in food and health for about 20 years, and I think actually the public's attention, and the scientific progress, and the attention of policymakers and industry in the last 10 years have been remarkable. I think we've been moving incredibly quickly toward trying to understand what to recommend, and trying to change the food system.
We have to remember we got here from at least 100 years of trying to make very inexpensive stable foods that would prevent hunger and micronutrient deficiency, and we did that. And now, the last 30 or 40 years, we've realized we've created a different problem, and now we're facing that problem. So I actually think we're moving quite rapidly, given the size and scope of the global food system.
What's your favorite way of summarizing how people should eat?
It's really challenging to wrap up the complexity of healthy eating in one or two or three words. If I had to be very brief, I would say: a high-fat Mediterranean diet. But then that still needs more definition. So, plenty of healthy fats, healthy oils, fish, nuts, fruits, beans — many minimally processed foods that are bioactive, and give rise to life when you plant them.
And then there's only really a handful of things to minimize. But those things represent about half the calories in the food supply: refined starches, sugars, processed meats, and other very highly processed foods that are rich in starch, sugar, salt or trans fat.
Now that's a good overview, but it's very hard for people because when they hear 'low starch and sugar' they think 'low carb' and they get mixed up. What about fruit? What about beans?
Also, people are so focused on calories these days that they're worried about fat. They think fried foods by definition should be unhealthy, or fatty food should be unhealthy, when if it's food that is fried with healthy oil or if it's dripping with extra virgin olive oil, that's good for you. You know, nuts are mostly fat, and they're the body's friend.
So the simple rules can be said fairly quickly: a high-fat Mediterranean diet, low starch and sugar. But when it gets to individual food choices — What's a healthy snack? What's a healthy energy bar? What about yogurt? What about cheese? — it does get confusing for people.
What messages most need to be counter-acted?
I think there are a few mistakes we've made as public health officials and scientists over the last 30 or 40 years. One of them is the focus on low fat. And while people sort of understand that they need to move away from low fat, they still might choose a low-fat salad dressing, or baked potato chips or low-fat muffins. There are all kinds of examples of people choosing low-fat foods, or worrying about nuts, or not putting enough plant oils on their foods, because they're worried there are too many calories. So I think the phobia about low fat is still a big problem.
I think the second problem now is we're so concerned about obesity that people are just counting calories rather than looking at food quality, and that's a huge mistake. We should be eating more calories from healthy foods, and counting them to increase those calories, not decrease those calories.
Lastly, when I look at policies, and I look at what industry is doing. There's a focus on reducing additives and getting rid of 'the bad' -- reducing salt, reducing sugar, reducing calories, reducing fat — in some cases which is not helpful. I think everybody should be focused — including industry — on increasing the good. How do we get more fruit, nuts, fish, healthy oils, vegetables, beans, into the food supply and into our diet and onto our plates?
What are the biggest remaining areas of uncertainty?
One of the most interesting areas of need for future science is dairy products. We've traditionally clumped all dairy foods together, thinking about calcium and vitamin D and calories, and just saying we need to eat three servings of dairy for calcium and vitamin D.
But you know milk is not yogurt is not cheese. Yogurt has active probiotics in many cases; cheese is fermented, and fermentation may cause different processes that affect our body.
So I think we really need to separately look at cheese, yogurt and milk, and also separately look at low-fat vs. whole-fat versions, things like homogenization which destroys milk fat globule membrane, which is this really interesting layer of fat that may be protective. I think understanding dairy better is really crucial, since this represents 10 to 15 percent of calories in the food supply.
The second big area of uncertainty and controversy is: We know that poor-quality carbohydrate is perhaps, calorie-wise, the biggest problem in the food supply for obesity and diabetes. People are eating a lot of low-quality carbohydrate, lots of refined starch and sugar, and there's much more starch in the food supply than sugar.
But then, how do you actually define a healthy starch or a healthy grain-rich food? That's complicated. Is it based on fiber? Is it based on the glycemic response or how fast it is digested? Is it based on whole grain content? Is it based on processing? That's actually not clearly established. The FDA is actually trying to consider how to define healthy whole grains. I think that's incredibly important.
And in terms of policy, are there no-brainer policies that need to be adopted?
There's no single silver bullet that's going to fix the problem. But there are clearly levers that need to be addressed.
· First, work sites need to provide financial incentives for healthier eating. It's now pretty normal to have financial incentives to join a gym. People should have incentives for healthier shopping, and there are programs that do that in the country.
· Secondly, we need to really leverage our health-care system. Food is completely missing from the health-care system; it's not even in the electronic health record. It's not in medical education. There are very few quality or reimbursement guidelines about food. Health care doesn't pay for fruit and vegetable prescriptions.
· We need to really think about financial incentives for industry, both carrots and sticks. So if you make unhealthy foods that have a huge societal cost, there should be a tax, or at least no tax break on those foods. And if you're going to make foods that are really good for us, then there should be tax breaks for that.
· Finally, we need to work on ways to leverage SNAP -- the largest food assistance program in the country, which is helping the one in seven Americans with food insecurity and is incredibly important — we need to leverage that money to make those 1 in 7 Americans also healthier in terms of eating better food.