Neha Pathak, MD, FACP, DipABLM:Welcome to the WebMD Health Discovered podcast. I'm Dr Neha Batak, WebMD's Chief Physician Editor for Health and Lifestyle Medicine. Today, we're diving into an issue that affects all of us, nutrition. We all know that what we eat plays a crucial role in our health. But recent research is giving us a clearer picture of just how much our diets have changed over the past two decades and where there's room for improvement.

A new study found that while Americans made some strides towards healthier eating between 1999 and 2010, we've unfortunately seen little progress since then. The good news is more people are paying attention to nutrition, and we're starting to see some healthier options in restaurants and grocery stores.

It's not a complete turnaround, but it's a step in the right direction. We'll talk about some of the bestways to take control of our health through the food we eat. But we'll also explore what it would look like if our approach to food went beyond individual choices and became a bigger part of health care.

That's one of the ideas we'll explore today, how food can be integrated into healthcare as a treatment and prevention tool. What options are already available for us to get things like medically tailored meals delivered straight to our homes? Depending on our diagnoses. We'll also talk a little bit about why nutrition, despite its critical importance, Is often missing from medical education, even though there's so much potential to make healthy eating a core part of patient care, whether you're interested in practical tips for improving your own diet or curious about the broader implications of nutrition policy and health care reform, you're in for a treat today.

this conversation is packed with useful insights and actionable advice from an international leader in the science and policy of food as medicine. First, let me introduce my guest, Dr Dariush Mozaffarian. Dr Mozaffarian is a cardiologist professor and director of the food is medicine Institute at the Friedman School of Nutrition Science and Policy at Tufts University.

Welcome to the WebMD Health Discovered Podcast, Dr Mozaffarian. 

Dariush Mozaffarian, MD, PhD: A pleasure to be here with you, Neha.

Pathak: I'm very excited to dig into our conversation, but before we do, we generally start our conversations asking our guests about their own personal health discovery, their aha moment that made them follow the work that they're doing. So, you're a cardiologist that is the director of this Food as Medicine Institute. Can you tell us a little bit about that aha moment that led you to this work?

Mozaffarian: As child of immigrants myself, I grew up in a household with two working parents who prepared incredibly healthy food for me throughout my life. And so I always had to just assume that was what, you know, others were doing. And yet when I entered medical school and.

Internal medicine residency and cardiology fellowship through those 11 years of training, you know, it became very clear to me that that was not the experience of most Americans and that food was actually the top issue facing most of my patients that this was what was causing their heart disease or diabetes or strokes or other metabolic conditions, and yet in all of that training, I barely learn anything about nutrition is you have also, you know, I'm sure experience in traditional training.

We learned about enzymes and what vitamin K does and chemical aspects of nutrition, but not really anything about what foods are healthy, how they interact with the body and so forth. And so for me that was an aha moment that, the top cause of poor health in my patients is not being addressed in my medical training or by the health care system. 

And that uneasy feeling has since been quantified by us and others that poor diet is indeed the top cause of poor health in our country and in the world. And then the second aha moment I had was I told myself, OK, at least I'll start reading all the papers I can find and I'll just devour them and understand myself so I can be the best doctor for my patients. This was in the nineties at the height of the low-fat diet epidemic when everybody was going out and having fat free cream cheese, fat free bagels, fat free frozen yogurt, fat free everything, the height of the low fat diet. And even then, in the nineties, the science didn't support a low-fat diet.

The science supported a minimally processed, healthful, high fat diet rich in many helpful foods rather than low fat. And so that was the second big aha moment that the science we have isn't being translated into policy and into practice. And so my career has kind of focused on those two points.

How do we ensure that food and nutrition is integrated into health care, and how do we ensure that that's integrated into policy and systems change to reach patients? And so the Food is Medicine Institute focuses on that. And it's a really exciting moment in our country when food based nutritional interventions like produce prescriptions and medically tailored meals, which we can talk about later, are actually being integrated now into clinical practice.

Pathak: So, I'd love it if you could help us take a little bit of a step back and help us consider what do you mean by food is medicine? What is the optimal diet?

Mozaffarian: You know a healthy diet is not rocket science on the one hand, and on the other hand, it's incredibly complicated. And so, there is kind of this path of communication. You can't define a healthy diet with a few words. So I can't say organic, even natural or unprocessed isn't always correct.

I can't say vegan or vegetarian or gluten free. I mean none of these single terms are enough because you need a few sentences. And so I'll try to be brief, but it is complicated. I think the first message is that you can't define a healthy diet by a handful of things that aren't in the diet, nutrients that aren't in the diet.

So you can't say, let's take out salt, let's take out sugar, let's take out animal products, let's take out fat, and then you're going to have a healthy diet. And likewise, you can have some of those things and have a healthy diet. If depending on the diet.

So I think the way that we have approached diet for cardiovascular metabolic diseases since 1980, low fat, low salt, low sugar, low calories, I think is incorrect. That's not very helpful for getting a person to healthy diet. So instead in its place, I think of foods in three categories or three buckets there's foods that are really healthy and we should be eating more of even for obesity. We should be eating more of those foods increasing our intake of those foods getting as much as we can filling our plates filling our snacks with these foods.

These are mostly minimally processed plant foods Although not all Fruits, vegetables, beans, nuts, and seeds at the top. Minimally processed whole grains, not necessarily all whole grains, but minimally processed whole grains. And then yogurt because of its active probiotics. Maybe cheese is going to start entering that category.

We can get back to cheese because of its amino quinones and fish because of its omega threes. And so that class of foods, which is again minimally processed foods, rich in nutrients that nourish the microbiome, nourish our health, and also, again, not very processed, and maybe we can get back to why food structure and processing is important.

We should be eating much more of those. And then there's foods in the second category that are kind of neutral foods, foods that, you know, you can eat in moderation, you don't have to have them, you don't have to avoid them, they don't deserve halos. They don't deserve devil's horns.

This includes most minimally processed animal products. And so cheese, poultry, eggs. milk, unprocessed red meat and butter and in that list, cheese is a little bit probably higher in the list toward benefit because it's the top fermented food consumed in many countries and like natto in Japan or kimchi or kefir and other countries were learning more and more about the benefits of fermented foods and unprocessed red meat, probably a little bit lower on the list towards harm because of the heme iron and the pro inflammatory products in meat, not saturated fat. That's not the problem. The problem is the heme iron. And there were a few papers actually just published this week from others on that topic. So that's kind of the middle category.

And then the worst foods that we should be absolutely avoiding and eating as little as possible, not never. You might still want to have them once in a while, but eating as little as possible is all the extremely processed foods, high in starch, sugar, and salt, and then also processed meats, which are preserved with, with salt, and nitrates like Including low fat deli meat, sausage, salami, bacon, you know, processed meats have arms and I say starch, sugar and salt rather than fat, sugar and salt because most fats are actually good for us and we should probably not be scared of fat, but embracing fat.

It's really starch that's the problem and starch is even a bigger problem than sugar. We've become a little bit obsessed with sugar as a negative thing and too much sugar is a problem, but, there's way more refined starch in the food supply. And that's all the rice, all the, white potatoes, crackers, energy bars, overcooked pasta, cereals, refined breakfast cereals, white bread.

And so that's really starches is glucose. And so starch is a big problem. And so I think those three buckets are what I recommend to people. And I have a graphic that I hand out to patients about this, you know, eat as much as you can of the foods at the top. The foods in the middle eat in moderation and the foods at the bottom, try to avoid.

And so when a patient asks me, you know, should I be having cheese on my bread? I say, eat the cheese, avoid the bread. There are healthier choices than cheese, like nuts and seeds and berries and beans, but there's many worse choices like white bread and white potatoes. So, I think it’s kind of a diet that's looks like a traditional Mediterranean diet.

Rich in healthy fats, rich in minimally processed foods, occasional fresh animal products. It looks like a traditional Okinawan diet, you know, which has lots of vegetables and seafood from vegetables and, from the sea and seaweed and other things. It looks like a lot of traditional diets around the world, that are really rich in foods that our ancestors as hunter gatherers, you know, really focused on.

Pathak:I think that that sort of characterization is very helpful. And I find that with my patients as well, sometimes I talk about it as yellow light and red light foods. It's interesting because I think it goes back to your earlier point where we just kind of want that one word or that one term and a lot of people are so bought into it.

Like I'm following keto right now or I'm following the Mediterranean or I'm doing that. So I think it just does become helpful to have these buckets for people to really sort of draw from rather than identifying with a particular term, which can become very confusing.

Mozaffarian: Yeah, I agree. And, you know, natural and unprocessed gets you toward the truth, but can be misleading. And so, you know, fries and a Coke can be 100 percent natural. You know, you could get a Coke that's all made with cane sugar and fries that are cooked with you know naturalized sole fries and a Coke.

So, it doesn't get you all the way there. but I think if people think about basically, I need to shop and get food ingredients and cook. Or if I'm going to go to a restaurant, I need to really look at the menu and try to get dishes that have fruits and vegetables and fish and nuts and seeds.

And if I want to buy packaged and prepared foods, which is really where the complexity, most complexity is, I have to really look carefully and understand nutrition to try to find ingredients foods that are less processed and have some of these, protective foods in them in that first bucket.

Pathak: I grew up vegetarian but was a very unhealthy vegetarian for a lot of my life. Because to your point, French fries, pizza are also part of a vegetarian diet. 

But even when we're thinking about ourselves as a vegetarian, and we're really eating foods in that green light category. How can we be really thinking about it? Besides the fact that they shouldn't be processed or ultra-processed.

Mozaffarian: I've actually seen this in patients and also friends and family, people who go on vegetarian diets and gain weight and feel less healthy because they're eating so much refined starch. And that's the big challenge of vegetarian, pure, especially vegan diets is all the starch, all the rice and bread and potatoes and other things.

And so, as I mentioned, you know, avoiding animal products per se doesn't define a healthy diet because yogurt is good for us. Fish is good for us. Cheese is probably good for us. Poultry, eggs, pretty neutral. Butter, pretty neutral. Unprocessed red meats, a little bit harmful for diabetes. So avoiding those and having unhealthy plant foods is a problem.

So it really is about understanding, I think, the harms of starch. Because if you start to understand what starch is. Starch is the endosperm of grains like wheat and corn and rice. Most commonly it's the starchy stuff that gives all the calories. And also in potatoes and other starchy vegetables.

Starch is long chains of glucose. This is where chemistry matters. It's literally glucose is what starches. And so, when you eat refined starch, that's been stripped of its natural food processing. And so, for example, you have white rice as opposed and brown rice, unfortunately, isn't that much better.

But let's say white rice as opposed to a steel cut oat or white rice as opposed to or amaranth or wheat berries where there's some intact food structure that refined starch gets digested by amylase in the mouth within 30 seconds and starts to get broken down into glucose. And in fact, if you keep some white bread or white rice in your mouth for 30 seconds or 60 seconds it'll start to taste sweet from the glucose.

And then by the time it gets into the stomach and the small intestine, it's rapidly and quickly digested. And so as you know, Neha, there's a measure of the burst of glucose from foods called the glycemic index, which measures how quickly glucose gets into your bloodstream. A hundred grams of rice or a hundred grams of bread has a higher glycemic index than a hundred grams of sugar because sugar is glucose and fructose, which has lower glycemic index. And so if you look at starch and you say, that's sugar in a way, it's hidden sugar. I try to explain to patients that starch is a hidden sugar. It doesn't mean never eat it.

I enjoy bread. I enjoy rice. You know, I enjoy corn, but have it as the side of your plate, have it mixed with healthy oils and minimally processed foods. Think of it as the side. Not the center of your plate. And that's a very different message from the 1992 USDA food pyramid which has since been retired, but Americans don't know that where you had refined grains and starches at the bottom of the food pyramid. So, we really have to take that bottom of the food pyramid and put it toward the top. 

Pathak:  Your work helped to inform the White House conference on hunger, nutrition, and health. I would love it if you could talk a little bit about that work. 

Mozaffarian: We talked a lot with congress and the White House about the need for the conference, among others, and we also put together an independent task force and went all over the country and had meetings and met with people all over the country to give recommendations to the White House for what we should be doing to address hunger, nutrition, health, and many of our recommendations were adopted, I think we helped positively influence it.

I'm torn Neha as a physician and on a podcast communicating to people. I'm torn about how important knowledge and education and communication really is food is the only major segment of our economy where most of the products are knowingly harmful and we just let them stay there and we don't do anything about it and we expect people to figure it out for themselves.

Imagine if we knew that mobile phones were causing 70 percent of diabetes in this country and about 10 percent of cancer and 45 percent of cardiovascular disease were being caused by our mobile phones because they were emitting something, right? We would immediately take them off the market, right?

Imagine if we knew that our houses were being built in ways that were not earthquake safe or that could go up in flames or that had asbestos in everything or lead in all the paint we would get rid of that. 

And so, this is where I'm a big believer in systems change and policy change. And that's supported by lots of science. If you tell somebody about tobacco that they shouldn't smoke. If you tell somebody about physical activity and communicate to them, if you educate people about drug compliance and taking their medicines, there are some individuals who will actually take that and make that change.

But on average, those are pretty ineffective interventions. You can't reduce smoking and increase physical activity and improve drug compliance. Or really improve diet very much with knowledge and education alone. We really need to have all the systems to make this easier and to make this simple.

And so that's what we focused on in our recommendations to the White House. That's what Food is Medicine focuses on is how do we create systems, structured systems, changes to make healthy food, the easier choice, the default choice, the less expensive choice for everybody in particular. Americans who are low income or lower education or from racial and ethnic minorities or living in the south where there's pretty big dietary and health disparities.

And so as for the example of Food is Medicine, Food is Medicine is a systems intervention within health care where instead of the doctor, instead of you or me going to my patient and saying, hey, look, you need to have more fruits and vegetables. You need to more nuts and seeds. I want you to have extra virgin olive oil. I want you to have seafood. I want you to cut out the refined cereal and sausage and McDonald's and all this. Good luck. See you next year. 

In addition to advice, we give them a prescription and depending on their medical condition, depending on how sick they are, depending on whether they can shop and cook by themselves, you might give them a prescription for fully prepared meals that will be delivered to their home that are tailored exactly to their medical condition.

You might give them a prescription for medically tailored groceries where they can with a debit card or credit card or with home delivery or by shopping online, they can get. Specific curated healthful foods that are good for their disease. Deliver it to their home, or you might just give them a very simple fresh fruit and vegetable produce prescription, which is just very basic, a little extra money, 50, 100 a month to buy fruits and vegetables.

You combine that prescription, which pays for the food, just like your prescription pays for your CAT scan or your blood pressure lowering drug or your surgery. You combine that prescription with some regular nutrition and culinary education. You know, high touch, using telehealth, using videos, other things and that is what's happening now in Food is Medicine across the country.

It's happening in Medicaid. It's happening in Medicare. It's happening at the VA. It's happening in employer-based plans. It's still not happening for most Americans. It's still kind of a patchwork, but it is happening and billions of dollars a year are now being implemented on these programs and so to me, that's really exciting that the health care system instead of only prescribing drugs and surgeries and devices and expensive diagnostic tests can also prescribe food and insurance will pay for the food because it makes sense.

And I want to emphasize two things about Food is Medicine. One is that we're not talking about prevention only. We're not talking about eat your food. It's good for you. You know, help you 20 years from now. We're talking about treatment. We're talking about patients with diabetes. Women with high-risk pregnancy, patients with heart failure, patients with severe uncontrolled obesity, including those who are on GLP 1 agonists and so on and treating their condition and making them feel better and improving their health within months.

And then secondly, what I'm really excited about with Food is Medicine is this is one of the first innovations I've seen that will actually reach people that need it the most. You and I have seen so many new drugs, new devices, new surgeries, new tests, that inevitably when you look there's disparities in who gets them.

People who are lower income, racial ethnic minorities, lower educated tend to get these innovations less. Food is Medicine specifically targets people at most in need and with social needs. It's for anyone with these disease conditions, but it really looks for and targets people with social needs.

So it has the ability, the potential to both improve health and improve health equity while bringing health care costs under control. So that's just one example. You know, Food is Medicine and health care isn't going to solve everything around food. It's not going to end all of our problems. But within health care, it's a really important way that we can help our patients beyond just giving them advice and education.

Pathak: I'm so thankful that you are speaking about this innovation so that anyone who's listening, who may find that this would be a beneficial treatment in for a family member or someone that they know, can seek out more information about this.

To your point, we're not going to necessarily be prescribing these for patients that don't have these conditions, but yet it's a very powerful preventive prescription.

So, I’d just love your thoughts on that person who's the head of the household, or one who's doing the shopping and who is not going to be eligible for such a prescription.

Mozaffarian: So the Food is Medicine is a pyramid. We have a Food is Medicine pyramid that has sort of fully prepared meals at the top for the sickest patients then medically tailored groceries then produce prescriptions. But beneath that for the general person population we need to really think about how we first improve our federal nutrition programs like school meals wick for pregnant women, snap for low-income Americans.

And then below that, we have to have population level programs that make grocery stores and restaurants, restaurants, you know, healthier for everyone and easier for everyone to, you know, shop healthier. And so, we have proposed and we're working on a suite of policy and system changes that can help make those things happen as well today, while the average person is waiting for that, you know, I think that I would give a few take home take home messages and rules first.

It's hard. It's complicated. it takes time, but to shop and cook as much as possible. And when I say cook, you don't need to have a four hour, you know, slow cooked French meal, right? my wife and I, we assemble a lot like we get ingredients and we assemble them. You know, you grill some salmon.

You grill some asparagus, cook up some, thin, beautiful, Sangak Persian bread and put some melted cheese on it and you have yogurt on the side, and it takes 20 minutes, and you have dinner for five. So assembling is really good. Salads can be assembled with all kinds of toppings, smoothies in the morning with nuts and fruits and other things. Assembling but that takes time and planning and preparation.

And kitchen resources and dollar resources to grocery shop, but that's still cheaper from a pure cost perspective than going to restaurants. And so, I think that's the first take home message is the more you can avoid pre prepared foods. and then I think the second message is then within the foods you buy in the grocery store or in restaurants or in cafeterias to really seek out and learn to enjoy and love fruits, vegetables, beans, nuts, seafood, yogurt, you know, these other foods.

And once you start eating healthy, you start feeling better, within weeks sometimes in terms of mood and sleep. And other things I've seen this with my patients. And once you really after a few months, you can't go back, you’re like oh I'm going to go to a fried chicken place and at a fast food. And because I'm in the mood for it I'm going to go get some fries from I'm going to grab a giant starchy bagel and have that for lunch. 

You feel sick afterward for a couple hours. You're like, oh, I wish I hadn't done that. And I think what's sad to me, Neha, is most Americans feel that way all the time, but because they're eating that way three meals a day, seven days a week, they don't even know they're feeling sick. They've never even had that several weeks of healthy eating to start to feel they're like their best version of themselves.

I think ultimately it's a tough road for every patient to do, but my mission is to try to help patients to do that both in the clinic, but also through what we can do outside the clinic.

Pathak: I just really appreciate your time with us today. And of course, the work that you're doing for systems levels change. So besides just the one on one in the office with that one patient, what you're doing to bring healthier eating to all of us as a population. So I am just thankful for your time today and for the work that you're doing on a daily basis.

Mozaffarian: Well, thank you for your commitment to lifestyle medicine and, you know, having more doctors like you who really understand the power of lifestyle, good nutrition, physical activity, sleep, stress reduction, avoiding substance abuse. That's the recipe for health, right? It’s not rocket science.

So thank you so much for helping patients every day.

Pathak:Thank you so much for being with us today. We've talked with Dr Dariush Mozaffarian about the transformative role of nutrition in health care and how the food we eat can be one of the best prescriptions for health. Dr Mozaffarian emphasized a couple of things for me today that I'm going to take away.

So one is the importance of cooking more meals at home, choosing minimally processed foods, and when possible bringing my own lunch and snacks to work. Dr Mozaffarian also emphasized the need to shift away from outdated dietary advice, like the low-fat craze of the 1990s. And instead of focusing on fats, carbohydrates, and other macronutrients focus on minimally processed foods, nutrient rich foods, basically the whole foods like fruits, vegetables, nuts, fish, whatever you find palatable that you're going to eat, consume those natural foods and limit highly processed foods, high in starch, sugar, and salt.

He also discussed the importance of integrating nutrition into healthcare through initiatives like produce prescriptions and medically tailored meals, which are beginning to be adopted in programs like Medicaid and Medicare. And he was recently on Capitol Hill, educating policymakers and lawmakers about all of the amazing work that's being done in the food is medicine space. To find out more information about Dr Mozaffarian, please take a look at our show notes. 

Thank you so much for listening. Please take a moment to follow, rate and review this podcast on your favorite listening platform. If you'd like to send me an email about topics you're interested in or questions for future guests, please send me a note at [email protected]. This is Dr Neha Pathak for the WebMD Health Discovered podcast. ​