What are processed foods, and are they bad for us?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Are Processed Foods Bad for Us?

We hear a lot about eating “real” foods and avoiding overly processed foods. Food writer Michael Pollan famously said his rules for the ideal diet were to 1) eat food, 2) not too much, and 3) mostly plants. He went so far as to say that any food with more than five ingredients, or an ingredient you can’t pronounce, is probably bad for you. But what’s the evidence that this is right?

Thanks to the work of investigators at the NIH, we have new evidence that processed foods should not make up the bulk of our diets. Researchers paid twenty volunteers to live in a research hospital for a month. Ten of them were men, and ten were women. The volunteers were randomly assigned to eat either an “ultra-processed” diet or an unprocessed diet for two weeks. The diets were identical in the number of calories and amount of nutrients like fat, sugar, protein, and fiber. The volunteers were observed closely for food intake, and frequent testing was done to determine how many calories they were burning.

An example “ultra-processed” meal was:

• steak (Tyson)

• gravy (McCormick)

• mashed potatoes (Basic American Foods)

• margarine (Glenview Farms)

• corn (canned, Giant)

• diet lemonade (Crystal Light) with NutriSource fiber (researchers had to add fiber to the drinks in the processed diet to match the fiber of the unprocessed diet)

• low fat chocolate milk (Nesquik) with NutriSource fiber.

In contrast, the unprocessed meal on the same day was:

• beef tender roast (Tyson)

• rice pilaf (basmati rice (Roland) with garlic, onions, sweet peppers and olive oil)

• steamed broccoli

• side salad (green leaf lettuce, tomatoes, cucumbers) with balsamic vinaigrette (balsamic vinegar (Nature’s Promise)

• orange slices

• pecans (Monarch)

• salt and pepper (Monarch)

In spite of having equal numbers of calories available to them at every meal and snack, the people eating the processed diet ate about 500 calories per day more than the people eating the unprocessed diet.

After two weeks each person in the study was “crossed over” to the opposite diet from what they’d started on. That is, the processed diet folks started eating the unprocessed diet, and vice-versa.

What the investigators found was dramatic. In spite of having equal numbers of calories available to them at every meal and snack, the people eating the processed diet ate about 500 calories per day more than the people eating the unprocessed diet. This showed up in their weight: the processed dieters weighed, on average, 2 pounds more at the end of two weeks than they did at the start of the diet. All their extra weight was in the form of fat.

This finding could have a real impact on your employees’ health. When you are thinking of food for a large function, or thinking of how to contract food in an on-site cafeteria, it may be worth looking at the NOVA food classification system and working to increase the availability of Group 1 foods, those that are “unaltered following their removal from nature.”

Examples of these would be:

• vegetables

• fruits

• potatoes (fresh, packaged, cut, chilled, or frozen)

• whole-grain wheat, oats and other cereals

• eggs

• fresh, chilled or frozen meat, poultry, fish and seafood

• pasta, couscous, and polenta

• milk or yogurt without added sugar

Bon appetit.

Links for Monday, October 8, 2018: Ashton Lambie, vibrator myths, really old-timey pumpkin spice, Mac is skinny, and the thyroid diet

Since I’ve been hustling to finish a couple big projects the last month, we’ve fallen behind. Got some catching up to do!

Meet Ashton Lambie, Kansan and new World Record Holder in the 4k Individual Pursuit

I've watched that giant 'stache ride away from me in approximately 1,000 gravel races.

Your favorite party story about how doctors used to manually "stimulate" the genitals of hysterical women with vibrators? That one? It's probably a myth.

And we're all worse off for it. 

Even prehistoric Asians couldn’t resist the #PSL

“Look, it's not that hard. All you need to do is lift weights six days a week, stop drinking alcohol, don't eat anything after 7 p.m., don't eat any carbs or sugar at all, in fact just don't eat anything you like, get the personal trainer from Magic Mike, sleep nine hours a night, run three miles a day, and have a studio pay for the whole thing over a six to seven month span. I don’t know why everyone’s not doing this. It’s a super realistic lifestyle and an appropriate body image to compare oneself to.”

No more cultivation of mass for Mac. I hate, hate, hate the culture that pretends that models and actors/actresses can eat all they want and somehow magically stay thin. Maybe Rob McElhenney gets to say things that actresses can’t.

Is there such a thing as the “thyroid diet?”

Within reason, no. (registration required)

Just minutes a day

Remember the proliferation of exercise gadgets in the 1990s? You had the knee squeezer:

The sit-up machine: 

I don't see how this is better than a sit-up.

The aluminum pretzel:

I'm sensing a theme here...

And many, many others. What they all had in common (in addition to being highly inefficient ways to part you from your money) was their promise to turn you from "before" to "after" in some small period of time daily, usually under 30 minutes. 

Newsflash: doing anything--anything--physical for 30 minutes a day is going to help you out. It doesn't have to be a gymnastics routine. Hell, try doing push-ups, planks, and crunches for 30 minutes a day. It's a lot of work.

Both pictures are "after." Where can I buy those shorts? Rowrrr.

But that's all an aside. Here's the thing I'm really thinking of today: I’m not sure how may times I’ve had a parent or grandparent of young kids tell me how much physical activity he or she gets as a result of “chasing around a two-year old.” I’ve always been suspicious of the claim. Don’t get me wrong--parenting, especially at the toddler phase--is exhausting. But it tends to be exhausting in the way a stakeout is exhausting, mostly from monotony and sleep deprivation. It’s emotionally taxing because of the lingering self-doubt about the quality of your parenting and the everyday small decisions you fear will lead to some real harm if made improperly. Physically, it never seemed demanding at all with my two kids. There was some lifting, sure. But most of the parents I see in public with their kids are sitting somewhere gazing into their smartphones. It’s the kids who are doing all the physical activity. The parents are unlikely to take twenty steps in an hour, it seems. [note: none of this cynicism applies to daycare workers, most of whom really hustle]

Obviously I’m a little jaded. As I write this, I’m sitting in a fairly spectacular local park, taking part in a fundraiser. I can see eleven parents from my perch at a picnic table (at least I think they’re parents. They’re sitting adjacent to the playground with small children zipping between them. Oh, and there are 12 if you count me). Of the 12, twelve are either writing (that’s me), texting, or eating. Zero are interacting with children in any physical way. In an unusual turn of events, I’m actually primed for some moral superiority, since the kids and I got here by bicycle, in the #familypeleton, so I have the ~3.5 miles to the park and the 3.5 miles home on my side. That's enough self-congratulation for the day. My point is, being with your kids might bring you joy most of the time, but it won't bring you physical activity unless you do it self-consciously, just like any other activity. 

What got me thinking of this is the fact that I’ve had innumerable conversations with people about physical activity over the last decade in which one or both of us advocated for “Simple strategies to add physical activity to your routine!” These discussions were often irrationally enthusiastic about the awesomeness of parking at the far end of the parking lot, or substituting a rake for a leaf-blower, or using a whisk instead of an electric mixer. You get my drift, I hope. Here’s the problem: it’s almost all bunk. Desperate, depressing bunk. And I say this as the person who has on many occasions been on the giving end of this advice. Now, before Blue Zones fans come at me with pitchforks and torches (both good ways to “Add physical activity to your routine!”, by the way), let’s perform a little thought experiment.

Let’s imagine that you wake up from a routine surgical procedure to find a doctor solemnly standing over your bed.

“Justin, I have some bad news,” she says as she pulls up a chair. Your name is Justin in this dream, by the way.

“Your appendectomy went fine. You’re going to heal right up. But you had a rare complication of the anesthesia, and it appears you’re now paralyzed from the neck down. The good news [doctors always try to segue into the good news as quickly as possible, amiright?] is that you’re still able to breathe on your own, so you shouldn’t have any trouble talking, and you won’t need a ventilator.” As you try to shake off the last remains of the sleeping medicine, and as your spouse softly weeps at your side, the doctor goes on. “But you won’t be able to do any intentional physical activity beyond breathing, talking, smiling, and blinking.” She then explains that the condition is likely permanent, at least as permanent as you are.

As you let this news settle over you, what will you miss? Will you miss your thighmaster or ab cruncher or aluminum pretzel time? I hope not. But if so, that's cool. Will you miss mowing the lawn? Maybe, if you’re one of the guys Lowe’s advertises to in the springtime. Will you miss using a whisk? Well, I guess, insofar as you’ll miss cooking in general. (note: Julia Child has a great old clip in which she talks about how normal cooking should lead to the cook getting sweaty. It’s awesome. You should look for it. I'd link it, but I can't find it, and I'm in a hurry.) But I’m willing to wager that the walk across a shimmering, sweaty, oil-stained parking lot upon which you’ve intentionally parked your automobile far, far from the entrance to the big box store is something that approximately zero percent of us would miss. Zero percent of responders to this scenario would miss running a vacuum cleaner, or washing their tile floor by hand, or any of the 1,000 other “strategies” I’ve heard in this regard.

What would you miss? Dancing with family at weddings, maybe. The spray of water on your face as you waterski. I’d desperately, achingly, miss my morning cycling route that takes me through the sunrise in summertime and through a crystal wonderland in the winter. I know this because I've been sick lately, and I fear the cold air would make me sicker. I’d miss the bike ride to school with my kids. I’d miss the competent, reassuring thud of a frisbee into my outstretched hand. I’d miss the brace of cool water against my face the first time I dive into a pool in the springtime. I’d miss...nothing at all related to parking.

Here’s my point: Movement isn’t just a utilitarian product of 85 million years of evolution. It isn’t just a means of getting from point A to point B. It is a source of joy. So, sure, park at the edge of the Target parking lot. But even better, leave your car at home and find joy in the 30-minute bike ride or hour walk to the store because it brings you joy, is good for the planet, and it saves you money. Instead of burying your face in your smartphone while your kids play, take pleasure in helping your kids hunt fireflies or throw snowballs or walk around the neighborhood for 30 minutes in the evening. Take a big step, not a small one. Move because it makes you feel good, not because it adds steps to your FitBit.

Links for September 11, 2017: insect burgers, lessons from the PURE Study, death row food, and plastic in the water

I'm not bothered at all by the thought of insect larvae burgers. Are you?

For reasons I can't figure out, Swiss law allows use of only mealworm larvae, house crickets and migratory locusts. But apparently they taste fine:

The burger itself has little white specks of rice inside with traces of carrot, paprika, chili powder and pepper. After a hesitant bite, the main flavors that come out are the spices. The texture is curious, a bit like a meaty falafel with a crunch. An aftertaste lingered — but maybe that was just my subconscious playing tricks.

Sales are apparently brisk in a very limited release so far. 

See also: Chapul cricket bars, which are delicious, and the Impossible Burger.

Marion Nestle points out what we already know about the PURE Study (that's Prospective Urban Rural Epidemiology): Fruits, veggies, and legumes are good for us.

And refined carbohydrates and sugar are bad. The study's "high fat" diet didn't even approach the amount of fat that most of us eat (18-30% versus 35% in the US), so it's impossible to really say what the study proved in regards to fat intake. 

See also: David Katz on PURE, James Hamblin on PURE.

On death row, food rivals porn as an obsession for inmates.

Text below, in case you want to avoid reading the grisly details of a murdered family:

The second-most-prevalent obsession is food. Longo says he actually has two photo collections: nude women and gourmet cuisine. His letters to me are filled with food cravings: "a salt bagel with a full plain cream cheese schmeer from Einstein or Brueggers — toasted, of course"; "a cinnabon with a good cup of coffee"; "a pizza"; "honey-dripping baklava." To make the institutional meals more palatable, the men sometimes hold death-row dinner parties. Several inmates will pass their trays down the row to one cell — frequently, to Longo's. He'll combine all the food together, add commissary-bought items like hot sauce, peppers, and shredded cheese, then rebuild the plates "Cadillac style," as it's called, and send the trays back.

How all this plays into the choice of a last meal, I don't know.

94% of US tap water is contaminated by plastic fibers

I cannot find data on bottled water, but considering that most of it is packaged in plastic, I suspect it's no better. Why does this matter? Well, besides the ick factor, plastics have a notorious reputation in the endocrinology world as "endocrine disruptors," meaning that they exert a hormone-like effect on tissues. The most notorious chemical within plastics with this effect is bisphenol A, which among other effects acts as an estrogen mimic.

Weekend links for Saturday, August 17, 2017: post-apocalyptic Rio, money makes the Mediterranean diet work, DNA testing may not change behavior, and the folly of clean eating

A year later, the Rio Olympic sites are ruin porn. 

Is money the secret to making the Mediterranean diet work? 

To be fair: I don't know a lot about this literature at all, but I suspect that the same claim could be made of many interventions, dietary and otherwise, were the data known. The more money you have, the healthier you are in general. (link via kottke.org)

Knowing our DNA risk doesn't make us change our behaviors.

I need to investigate this further. The thrust of this article--that knowing our risky mutations doesn't make us behave any differently--flies in the face of some data I've presented in the past. 

Have we all fallen for "clean eating?"

I remain convinced that eating food that looks like food, in the Michael Pollan sense, is generally what we should all be doing. Like most ventures that people look to capitalize on, though, it has been taken too far: see the "influencers" in this article that actually make themselves sick with adherence to an irrationally vegetable-based, uncooked diet. (link via longform.org)

Diabetes testing is for the [puppies and hoglets and billies]?

The Ad Council (with pro bono help by the ad agency Ogilvy) has released an admittedly adorable set of ads to encourage people to get tested for prediabetes. I agree with them in principle: testing for prediabetes is cost-effective in the long-term as long as it's paired with a lifestyle program that reduces the risk of advancing to full-blown diabetes:

 (mandatory conflict of interest disclosure here: I'm a consultant on a CDC 1422 grant that aims in part to increase screening, detection, and referral of pre-diabetic patients into the Diabetes Prevention Program)

Baby hedgehogs are called hoglets.

But unfortunately, the "testing" offered in these ads is probably far too sensitive. That is, it picks up too many possible pre-diabetes cases and over-diagnoses people.

The evidence for my contrarian stance is here:

Investigators publishing in JAMA Internal Medicine found that, according to a test very similar to the one in the commercials, almost 60% of patients over age 40 would qualify as "at risk" for pre-diabetes, and 81% (!) of those over age 60 would qualify. These numbers are clearly too high; the total population of pre-diabetic persons in the United States is about 86 million:

That's less than 30% of the population. Yet the puppies-and-hoglets-and-goats test says that almost twice that number is at risk. The United States Preventive Services Task Force, on the other hand, says that testing should be done based on only two factors: age (between 40 and 75) and Body Mass Index (25.0 or above). This is a more reasonable strategy based on risk of heart disease, but it unfortunately misses almost half of cases. Investigators publishing in PLoS Medicine found that, by looking at 1.6 years of electronic health record data from 2008-2010, only 45% of patients ultimately diagnosed with diabetes or prediabetes would have been screened under the USPSTF criteria. 78% of the missed cases would have been missed because they were under age 40, and 29% would have been missed because they were too thin, with a BMI under 25.0.

So what's the answer? The answer is to keep yourself from ever transitioning from "person" to "patient" in the first place. If you think you're at risk, based on the puppies-and-hoglets-and-goats test, a hunch, a past blood test, or a soothsayer, make a change. Jump into a new life and reduce your risk. It'll be cost-effective in its own right: Ride your bike to work. Pledge to eat only food that comes from the produce section without packaging for a month. Go to bed earlier at night. Give up bug juice for good. Make a change. And then, only after you've adopted the life you want and deserve, think about whether or not you want to get tested on your own terms.

Links for July 17, 2017: open streets, placebo diets, hair dyes and cancer risk, the sedgwick county CHIP, bad sleep and junk food, and the lengthening of your life with dietary choices

Open Streets ICT is coming. Are you ready?

Are diets just placebos?

Is your hair dye increasing your risk of breast cancer?

Hair products, conveniently, seem to never get the wrath that other "artificial" lifestyle products (artificial sweeteners, preservatives, herbicides) get. Does this study change that? I doubt it.

Have you seen the Sedgwick County CHIP?

That's Community Health Improvement Plan, which is even more delicious than what you were thinking of...

Sleeping poorly may make junk food seem a lot more appealing.

The data is still maturing on this topic, but it's starting to look pretty obvious that we should all sleep more, for reasons obvious and not-so-obvious. I can speak from experience. During my internship, one of the hospitals I covered had a cafeteria that was free--in unlimited quantities--to trainees. I fell into a nasty habit of 3 am cheesecake binges during my in-house nights on call. It was ugly...

This paper deserves to be mentioned much higher in the list, but I may have more to say about it later. So...for the one-thousanth time, we have evidence that dietary choices can prolong or shorten your life.

Using one of three diet indices, investigators publishing in the New England Journal of Medicine found that "[a] 20-percentile increase in diet scores (indicating an improved quality of diet) was significantly associated with a reduction in total mortality of 8 to 17%." For the sake of comparison, taking a statin medication for cholesterol in high-risk people is associated with about a fourteen percent reduction in mortality. And to stave off the angry emails, I know that the statin data comes from high-quality randomized trials, while the referenced dietary study is observational. But still. 

June 13, 2017 links to confirm my pre-existing biases: No insulin, no BG checks and the cancer risk of physical inactivity and diet

If you're a diabetic person NOT on insulin, you probably don't need to be checking your blood sugar at home.

I like this paper for a couple reasons: first, it confirms what I already thought, which makes it my (and everyone else's, whether they admit it or not) favorite kind of paper. Second, it's by my old boss at UNC-Chapel Hill, John Buse (seen in that picture rocking a Willie Nelson-esque beard). Finally, it's a very practical look at what glucose monitoring is. If you're on insulin and can change your dose meal-to-meal and day-to-day, it makes sense to monitor glucose levels for safety and efficacy reasons. If you're on fixed doses of non-insulin medications, the act of glucose checking becomes much less practical, and just as big a pain in the ass as it always is. My screed against SMBG in this case, though, is called into question by the study. The investigators measured "health-related quality of life" at 1 year, and it didn't differ between the groups. So the people poking themselves didn't feel much worse than those who got off the hook. But I'm sticking to my guns: when it comes to self-monitored blood glucose levels in type 2 diabetics NOT on insulin, the juice (that's your blood) literally isn't worth the squeeze.

Some folks say that diet, physical inactivity, and the resultant obesity could overtake smoking in terms of cancer risk.

I say "no shit."

Things you can control right now

There are a lot of things you can't control: the weather, the stock market, your neighbor's loud music. But many, many things are under your control, as pointed out by Lori Deschene. And how well you do at seizing control makes a huge difference in your health and happiness:

Right now, you can control:

1. How many times you smile today.

7. When you pull out your wallet for luxuries.

11. How often you notice and appreciate small acts of kindness.

17. The type of food you eat.

21. How much exercise you get.

22. How many times you swear in traffic. [I'd amend this to say that you can control how often you're in traffic at all. If you're swearing at traffic, chances are you are the traffic.]

27. The attention you give to your loved ones when you see them.

28. How much you enjoy the things you have right now.

41. Whether you formulate a new plan or act on your existing one. [this is my favorite]

44. Whether you smoke or drink. [unless you’re an alcoholic, in which case you are in control of whether or not you seek help from a qualified practitioner]

50. How much rest you get at night.

Freedom from the vortex

Maybe you’re sick. Not throwing up or coughing up blood or having a fever, at least not most of the time, but you’re on a few medications, probably for diabetes or blood pressure issues or cholesterol, and your doctor picks on you to change your diet or be more active whenever you see her. Your medications cost a couple hundred dollars per month, and every second or third time you visit the doctor she adds another one, or replaces an old, cheap medication with a newer, more expensive one.

And maybe you weigh a few pounds (or many pounds) more than you want to. You’ve tried a few diets, mostly Atkins-type stuff, or low-fat, or calorie counting, and you’ve lost weight a few times, but each time the weight eventually came back.

Maybe you’re tired all the time. You feel bad when you get up in the morning, you are fatigued and achy all day, and you don’t sleep well at night. Your doctor thinks you might be depressed, and you’ve tried a couple medications for it, but they don’t seem to help.

And maybe you worry about money. You spend a lot of it on medications, and you go through the drive-through a few times a month even though you promise yourself that you won’t, and you end up working longer hours than you want to because you need to make sure the bills get paid.

Maybe you worry about the environment. You worry that our habits are putting your kids’ futures at risk, and you worry about it, but you aren’t sure what to do. A couple of times you’ve clicked the button to buy carbon offsets when you flew somewhere, but mostly you just try to ignore the problem.

And maybe it hasn’t occurred to you that these are all different manifestations of the same problem. You read that right. There is a very good chance that your diabetes is just another manifestation of the same set of problems as your weight and your fatigue and your money issues and even climate change.

We’re gonna talk about how. This blog is about your health, but not in the way that you’re used to talking about it with your doctor. It's not about the “blood pressure, blood sugar, cholesterol,” kind of health that makes you feel like a gadget someone is tinkering with. It’s more about the “What do I look forward to when I get out of bed in the morning?” kind of health. Or the “What can I do today to make sure I’m happier tomorrow than I was yesterday?” kind of health. Health as freedom: freedom from false choices, freedom from medications (not all of them, but some of them), freedom from the, *ahem*, Bravo Sierra that passes for medical advice from celebrities and celebrity doctors. I’m talking to you, Dr. Oz.

You’re not going to see click-baity posts on this blog about some new supplement or cellulite-destroying cream. You’re going to see posts on how you can take control of your life back. I’m not talking about a life jacket to protect you from the evil, swirling vortex of drug companies, subsidized faux-food, and carbon-spewing cars and factories. I’m talking about the freedom of learning how to swim your way out of that vortex altogether, put your feet on dry land, and walk away. All those people wrapped in spandex and padding away on a commercial gym’s treadmill under creepy fluorescent lights: do you think they’re free? They sure don’t look like it to me. You, with dry feet, having sprung once and for all from the vortex and now walking one foot in front of the other toward a happier, healthier life: that’s what freedom looks like.

I intend to be your guide along this path to medical freedom. I want to teach you a new way to think about your health; a way that allows you to make decisions that are your own and that will get you out of the vortex. You know the last time you had a bad cold, and you felt guilty for taking all the healthy days you had before that for granted, and you wondered when you would finally feel normal again? Remember how you said to yourself that you’d never take a healthy day for granted again? Once you claw your way out of the vortex, you won’t. And it will be because you MADE that next healthy day. You will have made it yourself, with your own hands and feet and decisions. If you believe me, I’ll see you at the next post.