#218 – Fixing the problems with ultra-processed foods | Dr. Tim Harlan & Dr. Rob Lustig

Ultra-processed foods harm people’s health and have ramifications for the overall health of the planet. While some food processing is necessary for recipes and feeding the globe, the food industry needs to make changes to ensure that processing doesn’t turn foods into harmful substances. Dr. Tim Harlan and Dr. Rob Lustig discuss the harmful ingredients in ultra-processed foods and how they impact metabolic health—as well as why the food industry has a moral obligation to make drastic changes.

Helpful links

Tim Harlan, MD: https://www.drgourmet.com/pr/index.shtml

Dr. Gourmet: https://www.drgourmet.com

Just Tell Me What To Eat by Tim Harlan, MD: https://www.amazon.com/Just-Tell-What-Eat-Delicious-ebook/dp/B0051QH2WM

The Metabolic Matrix paper in Frontiers in Nutrition: https://www.frontiersin.org/articles/10.3389/fnut.2023.1098453/full

Metabolical by Robert Lustig, MD: https://robertlustig.com/metabolical/

Robert Lustig, MD: https://robertlustig.com

6:17 — Nutrition science over the last decade has made strides, but the food industry lags behind

The food industry has a long way to go in making changes, but the science is clear that changes need to be made to benefit public health.

I think those of us who’ve been involved in trying to help make changes in how we eat and showing people how to eat great food that just happens to be great for you—that’s been challenging. But the last 10 years have been revelatory, and I think a lot of the work that we’ve been able to do together, I don’t think would’ve been possible 20 years ago.

8:57 — Food can be medicine, but it can also be poison

Food processing is necessary to a certain extent, but the food industry needs to work harder to ensure that processing doesn’t turn healthy food into something harmful.

I totally agree. Food is our shared experience. Right now, our shared experience is dying early. And that’s kind of the problem here. We have this thing that’s, sort of hanging over us now. I credit many, many of our physician colleagues… with this new concept of food as medicine, and writing prescriptions for vegetables at the vegetable market, and getting it covered by insurance. These are great ideas. The problem is food can be medicine, but it can also be poison. And that’s what we’re seeing. The question that you and I have now put to paper is: How do you figure out the difference? How do you tell what’s medicine and what’s poison? And what do you do about it? And so that, of course, has launched us into the world of ultra-processed food.

14:03 — The NOVA system classifies foods by their level of processing

NOVA classifies foods into four categories: unprocessed or minimally processed, processed culinary ingredients, processed foods, and ultra-processed.

I like to demonstrate to students and other clinicians how the NOVA system works. So for the audience, let’s take an apple as the example. NOVA class one would be an apple picked off the tree. NOVA class two would be apple slices, possibly de-skinned. NOVA class three would be apple sauce, macerated, potentially cooked with possibly sugar and maybe even a preservative added. NOVA class four would be a McDonald’s apple pie. Those are very different. That apple going in the McDonald’s apple pie is very different.

23:16 — DATEM is an example of processing

DATEM stands for diacetyl tartaric acid esters of mono- and diglycerides of fatty acids. It’s used to increase the volume and uniformity of bread.

In the bakery around the corner that’s making that nice fresh sourdough—let’s say with a pound of flour they make four, five, or six big loaves of bread. With a pound of flour using DATEM, you can make double that amount of bread. That’s why it’s so squishy because it’s like you said: it’s got a lot of air in it. And part of that is the sugar helps trap the moisture, but there are these other ingredients. A lot of these emulsifiers and such that we’ve looked are potentially pretty harmful to the body, starting with the lining of the gut and then moving onward from there to the liver and potentially the rest of the bloodstream and the brain.

24:03 — Emulsifiers potentially harm the gastrointestinal tract

Emulsifiers, found in processed foods, may erode the gut lining, leading to inflammation and leaky gut syndrome.

We learned—from the work of Elinav Lab Group in Rehovot, Israel, at the Weizmann Institute—that these emulsifiers are used in virtually all ultra-processed food in some fashion. Carboxymethyl­cellulose, polysorbate 80—these are all emulsifiers. And what are emulsifiers? I mean, think about it. They are detergents. One end is polar and the other end is non-polar. And that’s very specifically so that the fat in the water can basically be dissolved together, because the fat will bind to the non-polar end and the water will bind to the polar end, so you can lift out a stain. Basically that’s what Tide is. Tide is an emulsifier. It’s a detergent. So like what happens to your gut if you swallow a detergent? The detergent will actually eat the mucin layer right off your intestinal epithelial cell, exposing that intestinal epithelial cell to the sewer. That is your gut microbiome, and now you’ve got irritable bowel syndrome, potentially inflammatory bowel disease, and the phenomenon that we now commonly refer to as leaky gut, which leads to an inflammatory response and also ultimately a metabolic response.

28:17 — Sugar harms the liver, which can lead to metabolic disease

Protecting the liver helps protect metabolic health and overall health.

Anybody who’s listened to this podcast before knows—as far as I’m concerned—the liver’s where the action is because it is where metabolism meets inflammation. And if you protect the liver, basically you keep your insulin down. And if you keep your insulin down, all the chronic metabolic processes that drive all of those horrible diseases of metabolic syndrome, Type 2 diabetes, hypertension, dyslipidemia, cardiovascular disease, cancer, dementia, fatty liver disease, and polycystic ovarian disease will be ameliorated… Well, in order to get the insulin down, you’ve got to keep your liver healthy. You’ve got to protect the liver. So how do you do that? Well, don’t give it the substrate that makes it sick. It turns out the substrate that makes it sick is sugar.

37:01 — In the United States, people tend to consume too much omega-6 fatty acids

Omega-6 fatty acids are pro-inflammatory, while omega-3 fatty acids are anti-inflammatory. But in the United States, people tend to consume a larger portion of omega-6’s.

Trying to change that equation in how processed and ultra-processed food are created and making certain that that ratio of omega-6 to omega-3 fatty acids is flipped and really trying to bring it back down to normal. The challenge for this—without spending another hour doing a physiology lecture, which you probably don’t want to hear anyway—but the challenge to this is how those fatty acids are utilized, especially by the brain. How they’re utilized by a lot of other parts of the body, in the bloodstream, especially the pro-inflammatory impact of omega-6 versus the anti-inflammatory impact of omega-3. That in and of itself is a problem for atherosclerosis, or hardening of the arteries, leading to heart disease, stroke, etc. But the real thing that we think is critically important is protecting the brain in a way that you are changing that ratio by reducing the footprint of omega-6 and increasing the footprint of omega-3 fatty acids in the food supply.

43:48 — The food industry can find ways to make ultra-processed foods safer

Processed foods are necessary for feeding the entire planet, but better-quality processed foods are necessary for health.

I don’t think that processed food necessarily needs to go away. It just needs to be rethought. How do you take a product like ice cream and make it satisfying—make it delicious, make it creamy with the right mouthfeel, the right chocolatey flavor—but make certain that you’re reducing the emulsifiers that might be harmful, that you’re reducing the sugar footprint by using other non-nutritive sweeteners, that you’re adding in the better quality fats wherever possible, using chocolate (which many, many sources of chocolate have very high levels of cadmium) that’s safer, and making certain that we’re improving the supply chain, making certain that there’s integrity in the products that are being delivered. That’s a tall order.

46: 26 — Supply-chain changes are another piece of the equation

Amid the growing climate crisis, the food industry also needs to consider supply-chain changes that protect the environment.

There’s another piece of this puzzle that we also thought was important. For KDD and for other multinationals, and that is the integrity of other pieces—of the supply-chain packaging, sustainability for products, impact on the environment. As you said, at the top of the hour, Rob, there’s a lot that goes into this. There’s a lot that we have to think about in how we’re going to feed ourselves in the next 25 to 30 years. But those are doable. And our colleagues at the multinational food companies—they have the ability and they have the money. They really do. And I understand the concept of putting shareholders first, but those shareholders are also your patrons. And harming your shareholders has a double-edged sword, right? You might be benefiting their pocketbook, but are you harming their health? And that’s a really important moral and ethical decision that has to be undertaken by our colleagues in the food industry.

47:43 — Multinational companies have a moral obligation

Ultra-processed foods are harming us now, and if we don’t make changes to the food supply, we’ll continue to see children develop diseases traditionally seen in much older adults.

My concern is harming our children, because they are the future. Remember, children are the canaries in the coal mine. Whatever it is that we get sick with, they get sick with worse, which of course is why children now have the diseases of aging when they’re five years old: Type 2 diabetes, fatty liver disease, even cognitive decline—we are seeing in five-year-olds because of the food supply. Yes, you’re right. This is not a growth strategy, poisoning your population. This is what they said about tobacco. Do not poison your consumers. But that’s what we’re doing now. I have absolutely nothing against people making money, but they’ve got to make money doing the right thing, not the wrong thing.

Tim Harlan (00:00:07):

I don’t think that processed food necessarily needs to go away. It just needs to be rethought. And how do you take a product like ice cream and make it satisfying, make it delicious, make it creamy with the right mouth, feel the right chocolatey flavor, but making certain that you’re reducing the emulsifiers that might be harmful, that you’re reducing the sugar footprint by using other non-nutritive sweeteners, that you’re adding in the better quality fats wherever possible, and making certain that we’re improving the supply chain, that there’s integrity in the products that are being delivered.

Ben Grynol (00:00:58):

I’m Ben Grynol, part of the early startup team here at Levels. We’re building tech that helps people to understand their metabolic health. And along the way we have conversations with thought leaders about research backed information so you can take your health into your own hands. This is A Whole New Level.

(00:01:28):

One of the key messages that can’t be reiterated enough is to understand the makeup of food. What exactly does this mean? It’s the idea of understanding the inputs or the ingredients that go into food, as opposed to just looking at the nutritional content. There’s a big difference between the two. Dr. Rob Lustig, he calls it the metabolic matrix where it’s this idea of evaluating products based on their metabolic impact rather than their nutritional content. In his words, he always refers to a calorie is not a calorie because a calorie can be made up of many different things. It’s more important to understand what the nutritional label says, what is valuable, and what ingredients could be leading to metabolic dysfunction or some type of metabolic syndrome. The more of a foundation that people have for knowledge and understanding these labels, being able to read the ingredients and being able to decipher between good and bad inputs, the more they’ll be able to take their health into their own hands.

(00:02:28):

In the words of Rob, eat real food. That is the key. Eat things that we know have great macro and micronutrient makeup, and that will give us a better swing at metabolic health. And so Dr. Lustig, Rob, as many of you have come to know, he’s an advisor of Levels. He’s a friend to Levels. He’s an author of many books. He’s a mentor, he’s a researcher, and he’s somebody that we all look up to. He sat down with Tim Harlan, who is a professor of medicine at George Washington University School of Medicine. And he’s also an author and a chef. He has a very similar outlook in teaching patients that eating real food is the path to health. Dr. Harlan launched a site called drgourmet.com and that’s where he aggregates all of his work that is definitive evidence based information for diet, health, wellness, and lifestyle.

(00:03:20):

And so we know there are all these inputs which can impact our metabolic health, but how do we start to make change at the macro level? And so Rob and Tim sat down and discussed this idea of the metabolic matrix. The metabolic matrix is a strategy that they’re working to implement with the leading food company in Kuwait, the KDD, Kuwaiti Danish Dairy Company. It’s this idea of helping to educate people at the foundational level of metabolic health. The more awareness everyone has, the more change that we can make across the globe. Anyway, no need to wait. Here’s Rob and Tim.

Rob Lustig (00:04:03):

Good morning, good afternoon, good evening. I’m Rob Lustig. I’m emeritus professor of pediatrics in the division of endocrinology at UCSF, and also an advisor to Levels Health, and this is a whole new level. And when I say a whole new level, I’m really talking about a whole new level today. I have, as my colleague, my guest, my friend, my confidant, Dr. Tim Harlan. I’m going to let Tim introduce himself, but just so you all know, Tim has many, many attributes. One is he is an internist at George Washington University, head of the culinary medicine group. He is also a bonafide chef. And most importantly, he is the best dressed doctor in the world. And if you are listening to this, you are missing half the story. So Tim, welcome and thank you for everything, and thank you for doing this.

Tim Harlan (00:04:58):

It is really, really always fabulous to be with you, Rob, always.

Rob Lustig (00:05:03):

So why don’t we actually get started with that little tidbit. What was it that got you to move from being a chef to being a doctor? What was that spark?

Tim Harlan (00:05:19):

I grew up in the restaurant business. I started washing dishes when I was 12, back in the day when you could do the hat with permission from your parents and the school. I think my mother figured she knew where I was going to be on Friday nights if I was working. And I worked in the restaurant business throughout my teenage years and into adulthood. I managed my first restaurant at 18. I owned a little French bistro. I was a chef owner at 22. I actually closed that restaurant, in part to go to college, and actually with the idea that I’d get a hotel and restaurant management degree. And one thing led to another, I took a wrong turn one day and ended up in medical school. While I was in medical school, I began to kind of fuse what I had done partly because… And part of how I ended up in med school is my wife at the time had type one diabetes.

(00:06:19):

And you as a pediatrician, I think know the challenges, especially her having grown up in the sixties when diabetes care was much different and much less, the technology was very challenging .and she had some health problems, and so I had really begun to adapt what I did and was approached by a publishing group in Atlanta to create some patient education materials. And I wrote my first book about food while I was in medical school called It’s Heartley Fair. It’s kind of a food manual for patients with cardiovascular disease, and have been standing at the intersection of food and health for 35 years now, I guess, since that book was published. And up until recently, it was a very lonely corner. I think those of us who’ve been involved in trying to help make changes in how we eat and showing people how to eat great food that just happens to be great for you, that’s been challenging, but the last 10 years have been revelatory. And I think a lot of the work that we’ve been able to do together I don’t think would’ve been possible 20 years ago.

Rob Lustig (00:07:34):

Indeed. It’s like the sky opened up, and all of a sudden, everybody’s interested in food. It used to be that they were only interested in food for taste, and now they’re interested in food for health, for the environment, for climate, for economics. Food has sort of taken its place on the proverbial humanitarian plate. And I think one of the reasons is because we realize we have to feed 10 billion people by the year 2050, and we’re not going to have the land of the ocean to do it. And this has sort of generated a distinct concern around the world about, what are we going to do, especially as climate change gets worse and we are actually going to need four central valleys of California and we won’t even have one?

Tim Harlan (00:08:29):

I would posit that we’ve always cared about taste and flavor, and to a great extent, health. We’ve had long discussions about this over the course of the last few years, you and I, about how the food industry has changed, in many ways in an effort to address exactly what you’re talking about, getting food to more people. And it used to be malnutrition was the problem. People couldn’t get enough quality food, and that expansion unfortunately led to ultra processed food that in ends up being harmful. But I would posit that food… One of the reasons that all of those things that you ticked off about food is it is our universal experience. It’s our shared experience. We all eat. And we have to eat to fuel, but we also eat for pleasure and for socialization, and to be with family and friends and because it’s comforting. I think the challenge is exactly what you say, and that is how do we do that in a way that delivers the best quality and the best food, great food that just happens to be great for you, for our fellow citizens?

Rob Lustig (00:09:47):

Well, in fact, I totally agree. Food is our shared experience. And right now, our shared experience is dying early, and that’s kind of the problem here. We have this thing that’s sort of hanging over us now, and I credit many, many of our physician colleagues, [inaudible 00:10:08] and many others with this new concept of food as medicine and writing prescriptions for vegetables at the vegetable market and getting it covered by insurance. These are great ideas. The problem is food can be medicine, but it can also be poison. And that’s what we’re seeing. And of course, the question that, you and I, have now put to paper is, how do you figure out the difference? How do you tell what’s medicine and what’s poison? And what do you do about it? And so that, of course, has launched us into the world of ultra processed food. So Tim, why don’t you describe how we have come together and what our joint project that led to today’s podcast is?

Tim Harlan (00:11:03):

Yeah, I think you might be better at that, but I’ll take a stab at it. You and I have been connected for a while and I think have a shared ethos. You reached out to me about a project, gosh, I guess what, four years ago now maybe, that you were working on. It was a little mysterious at the time, but what came to light is that a Kuwaiti company, a dairy company by the name of KDD, was interested in transforming their product line. One of the owners of the company, privately held company, had undergone some health issues and wanted to really make certain that he was delivering the best quality products in a region of the earth that is very challenged by diabetes and obesity and food related illness. And you brought together a team that I am part of, the other members of that team, Andreas Kornstädt is a super fascinating computer scientist and information technologist who’s developed some really terrific data analytics software around food called Perfact. Wolfram Alderson, who is a food advocate and activist, as well as Rachel Gao, who is a nutritionist and specialist in fatty acid research.

(00:12:34):

I came to the table… I think you brought me to the table partly because I’m an internist in practice medicine every day and work with patients and see what the end result is like you do, but at the same time, I’m also a chef and still develop a lot of recipes, and also a lot of educational programming here at GW with the culinary medicine program and with the Culinary Medicine Specialist Board, which is the nonprofit that I help lead that helps educate healthcare professionals, and now food service professionals about healthy eating and how to transform the conversation that we’re having with our patients and our patrons around health and around food. And you come to the table because you’re a genius.

Rob Lustig (00:13:24):

I don’t know about that.

Tim Harlan (00:13:25):

You’re just an all round smart guy and a pediatric endocrinologist.

Rob Lustig (00:13:29):

Yeah. Okay. I’m a pediatric endocrinologist, and we’re a bunch of OCD data driven guys, is what we are. That, I’ll accept. The fact of the matter is we have a food problem. We all have a food problem, and that is because we switched our diet, and we switched it for ostensibly rational reasons. But we basically abdicated our ancestral diet, which, for lack of a better word, we can call real food, which we used to have, for this new thing, technologically driven, mass produced lots of flavor, lots of taste called ultra processed food. And our colleague in Brazil, Dr. Carlos Montero, who is a public health epidemiologist, recognized that it’s not what’s in the food that matters, it’s what’s been done to the food that matters. And that’s the difference between real food and ultra processed food, is what’s been done to the food.

(00:14:40):

He developed a system, a food classification system called Nova, which doesn’t stand for anything. It just means news system in Portuguese, but basically on the degree of processing. So I like to demonstrate to students and other clinicians how the Nova system works. So for the audience, let’s take an apple as the example. Nova Class one would be an apple picked off the tree. Nova class two would be apple slices, destemed, deseeded, possibly deskinned. Nova class three would be apple sauce, macerated, potentially cooked, with possibly sugar, and maybe even a preservative added. Nova class four would be a McDonald’s apple pie. Okay? Those are very different that apple going to the McDonald’s apple pie is very different. And one of the reasons why I wanted you on this scientific advisory team to advise KDD, was because all the steps that take you from that apple to that McDonald’s apple pie, and you knew what the interventions could be to be able to mitigate those risks.

Tim Harlan (00:15:59):

Yeah. And I think the Nova class four, probably as a different example, would be the apple juice, which is basically Coca-Cola in a way. And so the challenge is that our colleagues in medicine oftentimes, but have in the past, I think it’s changing, and certainly many of our patients and citizens in the community think that all four of those, the apple, the peeled apple, the apple sauce, and the apple juice are all fruit. And that they’re not all fruit. They’re all fruit derived. But as you go down the line, you basically selectively, one step at a time, strip all of the goodness out of that beautiful, poor innocent apple that you started with. And that happens, I think with a lot of food. The more technical example might be a wheat berry. So that wheat berry is… You know, can eat wheat berries whole, and they’re terrific in cereals.

(00:17:12):

And every step that you take across that of stripping away the brand, separating the endosperm, until you get to just white flour, which is essentially sugar, for all intents and purposes. They’re all wheat, right? They’re, all wheat products. But the further you get away from the goodness of that original ingredient, the more problematic it becomes. But to some extent, I think you and I both agree that we have to do that to some extent, and we do that to some extent because we make bread, right? Well, that would not be… That’s going to be Nova two or maybe even Nova three, depending on the quality of the bread. We have to do that because that’s how we eat, but trying to do that in the safest way possible without a lot of other added ingredients. And I think that’s where obviously we come to the table with this scientific advisory team, is what else is being done to that recipe, if you will?

(00:18:22):

Not just the actual ingredient itself, but now you’re going to put those ingredients together in bread. What else are you doing in that bread with stabilizers, emulsifiers, different artificial ingredients, natural ingredients, et cetera? Oftentimes folks who are looking at the package, and it’s just confusing. I have a friend of mine who says, “I can make bread or baked products with six ingredients, water, flour, butter, maybe some fat, some sort of leveling agent, salt and maybe a little bit of sweetener to activate the leavening agent, depending on what the leavening agent is.” But then you turn over that loaf of bread in the grocery store and it’s got 32 ingredients in it, where did all those other ingredients come from?

Rob Lustig (00:19:15):

Indeed. I always tell people the best way to understand this is to take a look at a loaf of grocery store bread versus a loaf of bakery bread that you bought at the bakery. And I say, how fast does each one stale? The bakery bread will stale in two days. The grocery store bread will stale in about three weeks. So what’s the difference? They’re both bread. How come the bakery bread stales so quickly? And the answer is, they added sugar to the grocery bread. Now, why did they add sugar to the grocery bread? Because the sugar doesn’t boil off when they put it in the oven at 450 degrees. The sugar stays put, and the sugar holds on to water. It’s hygroscopic, in the same way we put little grains of rice in our salt in an attempt to try to keep the salt from caking so that the grain of rice acts as a desiccant.

(00:20:18):

And so the sugar that they add to the bread holds on to water. It’s called water activity. And so it keeps the bread from staling for a much longer period of time. The problem is just that process alone reduced the health value of that bread. In addition, the other thing they did was they took the fiber out of the bread. One of the things that I learned that just floored me, just absolutely floored me, and I learned this from the guy who runs the bread lab at Washington State. His name’s Doug Jones. And I actually learned it at your conference, Tim, in New Orleans back in 2019, so I credit you for this, 25 to 30% of the weight of a wheat kernel is the husk, the brand. That’s a lot. I had absolutely no idea that was 25 to 30% of the weight. Now, that means that if something is whole grain bread, then the carbohydrate to fiber ratio, because the husk is the fiber, the carbohydrate to fiber ratio should be about three to one.

(00:21:29):

I dare you to find a bread anywhere in any grocery store that has a carbohydrate to fiber ratio of three to one, almost impossible. There are a couple. They’re rare. They’re like German fitness bread. They’re very dense, basically non glutenous because the husk is still intact. So the gluten is still inside the kernel. So they make a lousy sandwich because there’s basically no fluffiness to them. They’re very crumbly, they’re heavy as a brick. And if you threw it at somebody’s head, you could knock them out. Okay? That’s whole grain bread. Everything else is a joke.

Tim Harlan (00:22:15):

Right? But at the same time, I think perfection is the enemy of success, and we do want to eat great food that culturally and socially and comfortable to us. So I think that compromises… It’s pretty easy, however, to find bread that is more along the lines of maybe not quite one to one with the carbohydrate, or I’m sorry, two to one with the carbohydrate to fiber ratio, but you can get the three to one carb to fiber, four to one fairly easily, but it takes a little bit of work. The other challenge, I think with the bread is it’s not just that, all right, we’ve taken out that brand and we’ve taken out, stripped out all that goodness, and in the process a lot of the flavor also, but for industrial produced bread, as you mentioned, the stuff you get off of the shelf, the squishy white bread that you get off the shelf at the grocery store, there’s ingredients that are put in there for a lot of different reasons.

(00:23:29):

One of them, for instance, is DATEM, D-A-T-E-M. And datum is, it’s always difficult to say. It’s diacetyl tartaric acid ester of monoglycerides. That’s pretty much a mouthful. And there’s not a lot in there, of DATEM in the bread, but it’s specifically designed… Those monoglycerides, they sort of have been glommed onto some other organic acids, and basically it helps improve the yield of that flour. So in the bakery around the corner that’s making that nice fresh sourdough, let’s say they’d make, I don’t know, with a pound of flour, they make 4, 5, 6 big loaves of bread. With a pound of flour using DATEM, you can make double that amount of bread. That’s why it’s so squishy, because like you said, it’s got a lot of air in it. And part of that is the sugar helps trap the moisture. But there’s these other ingredients that potentially a lot of these emulsifiers and such that we’ve looked at that are potentially pretty harmful to the body, starting with the lining of the gut, and then moving onward from there to the liver ,and potentially the rest of the bloodstream in the brain.

Rob Lustig (00:24:53):

Indeed. So we learned, from the work of Elinav’s group in Rehovot, Israel at the Weizmann Institute, that these emulsifiers that are used in virtually all ultra processed food in some fashion, carboxymethyl cellulose, polysorbate 80, carrageenan, these are all emulsifiers. And what are emulsifiers? Think about it. They are detergents. They have a polar… One end is polar, and the other end is non-polar, and that’s very specifically so that the fat in the water can basically be dissolved together, because either the fat will bind to the non-polar end and the water will bind to the polar end, and so you can lift out a stain. Basically that’s what Tide is. Tide is an emulsifier. Okay. It’s a detergent. So what happens to your gut if you swallow a detergent? The detergent will actually eat the mucin layer right off your intestinal epithelial cell, exposing that intestinal epithelial cell to the sewer that is your gut microbiome. And now you’ve got irritable bowel syndrome, potentially inflammatory bowel disease. The phenomenon that we now commonly refer to as leaky gut, which leads to in inflammatory response, and also ultimately a metabolic response.

(00:26:17):

So this rubric of what’s in the food is not important. It’s what the food does to you that is important is how we ultimately came together in this KDD program to develop our principles of health. What makes a food healthy? And we came up with three principles that we could all agree on that basically fit the literature, and I want to go delve, do the deep dive on those three with you. Number one, protect the liver. Number two, feed the gut. Number three, support the brain. So why don’t you tell the audience how the liver gets protected, and I’ll pick up from there?

Tim Harlan (00:27:07):

Well, I think part of the first step for protecting the liver is to support the gut really well and feed the gut really well. And folks hear a lot about eating probiotics or prebiotics, et cetera, but what does that actually mean for the average person? Well, A, it means delivering great quality as natural a food as possible, and high fiber food in a way that supports the gut and protects it. The second step of that, as we talked about, is doing what we can to add those prebiotics of the fiber, et cetera, and then probiotics of other great quality fermented foods, et cetera, that in a way that helps support the gut microbiome. So we want to deliver really great quality, again, as whole of food as possible, as natural of food as possible, as close to the source as possible.

(00:28:23):

The second step, in feeding the gut properly, so you are protecting the liver, is to make certain that a lot of these added ingredients that we were talking about a minute ago, like the emulsifiers, monoglycerides, et cetera, et cetera, that we’re getting them out of diet and out of ultra processed food, which we, I think agree now is possible, that there are alternatives. Might cost a little bit more, but marginally, and it will require some retooling and some rethinking and some innovation, but it is absolutely possible. So step number one, feed the gut, feed it really well, because in that gut, three things happen. The first thing is digestion. We break up the food. The second thing that happens is absorption. We’re absorbing food across the lining mostly of our small intestine. And then the third thing that happens is the metabolism of that food and what’s happening. And that metabolism primarily begins to happen at the liver. So I’ll kick it to you to talk about how, after we have fed the gut properly, how are we going to protect the liver?

Rob Lustig (00:29:39):

Anybody who’s listened to this podcast before knows, as far as I’m concerned, the liver’s where the action is because it is where metabolism meets inflammation. And if you protect the liver, basically you keep your insulin down. And if you keep your insulin down, all the chronic metabolic processes that drive all of those horrible diseases of metabolic syndrome, type two diabetes, hypertension, dyslipidemia, cardiovascular disease, cancer, dementia, fatty liver disease, polycystic ovarian disease will be ameliorated. They will go down, got to get the insulin down. Well, in order to get the insulin down, you got to keep your liver healthy. You got to protect the liver. So how do you do that? Well, don’t give it the substrate that makes it sick. Now, turns out the substrate that makes it sick is sugar. Now, prior to 2013, the substrate that made it the most sick was trans fats.

(00:30:48):

But we learned, as early as 1957, that trans fats were poison. It took the FDA till 1988 to resurrect that information. The studies started being funded by NIH to start looking at the role of trans fats in chronic disease. By 2006, the FDA had added trans fats as a line item on the nutrition facts label. And by 2013, they were deemed poison. They were removed from the generally recognized as safe list, and now they are banned in our food supply. Having said that, there are ways you can make your own trans fats at home, like burning olive oil. That’ll make a trans fat. Okay? So it’s not like they’re completely gone, but at least the food industry is not using them at industrial doses. Well, now the trans fats are gone, sugar is the most egregious toxin to the liver.

(00:31:52):

And the question of course is, why is that? Sugar is “natural.” Sugar is celebratory. Sugar is apple pie and 4th of July, and your grandmother basically pushes it on you every time she sees you. How can sugar be a toxin? Well, there are two molecules in sugar. There’s glucose and fructose. The glucose is not a toxin. The glucose is what every cell in the body uses for energy. Glucose is so important that if you don’t consume it, your body makes it. That’s how important glucose is. But that other molecule, fructose, the sweet molecule, the molecule, we seek the molecule that makes sugar pleasurable, because glucose isn’t all that pleasurable, and you don’t see people going around chugging Karo syrup. That’s glucose. Okay? Fructose is the molecule that makes sugar worth the experience. Well, it turns out the reasons because fructose is addictive. It actually goes to your brain, activates the reward center in the same way nicotine, cocaine, heroin do.

(00:33:05):

It is in the extreme addictive, and we have sugar addicts. In fact, 20% of America are sugar addicts. So this is a major problem. But the food industry knows that and that’s why they put it in. The problem is what that fructose does to your liver, it is not able to be metabolized to completion. The mitochondria get sick. There’s an enzyme in mitochondria called AMP kinase. Fructose inactivates that enzyme directly, thus reducing your mitochondrial function, reducing your ATP generation, reducing the energy availability within your cells, which make them sick, and then they start dying. So fructose is a dose dependent chronic mitochondrial and liver toxin. So there’s no medicine for that. The only thing you can do, reduce the substrate, reduce the availability of that molecule. And so the second principle of our, what’s healthy is protect the liver.

(00:34:19):

Well, protect it from things that make it sick, well, like fructose. And there are other things too. Protect it from cadmium, which is an oxidative stress to the liver. Protect it from like you said, emulsifiers, possibly even protecting it from some artificial sweeteners, for instance sucralose that have hepatic effects, and aspartame that have hepatic effects. So basically keeping your liver in top flight condition is tantamount to promoting metabolic health, and it’s from our food. So that then leads us to the third precept, the third rubric of what we called our metabolic matrix. The protect the liver, feed the gut, support the brain. So Tim, why don’t you tell people why omega-3 are so important?

Tim Harlan (00:35:12):

Yeah, supporting the brain is actually one of the easier of all of these, because we’re talking about really changing the equation in what are known as essential fatty acids. So there are some fats that we need because our body can’t make them on their own, specifically omega-6 and omega-3 fatty acids. And the omega- and omega-3 has to do with how the particular molecule of fat is configured. They’re similar to each other but very different. We need both. We need to consume both. We need to consume both in a ratio of about four to one omega-6 to omega-3. So we need a little more omega-6, but we need the omega-3s as well. There’s two challenges here with this and that is that our food supply, with a lot of the poor innocent oils, like Dr. [inaudible 00:36:22] has talked about, get corrupted.

(00:36:25):

They get corrupt corrupted through hydrogenation where they actually are bubbled and changed, but they also are corrupted because a lot of those oils and fats that are very high in omega-6 are cheaper. And they also work a little bit differently with their viscosity and how they act in food and baking, et cetera, but mostly they’re less expensive. And consequently, they are used in a very high ratio in processed and ultra processed food in western society, and now all across the world. And the ratio that we’re getting here in America is probably somewhere between about 16 to one, omega-6 to omega-3, maybe as high as 20, or even higher, 20 to one omega-6 to omega-3. And so a lot of beating the drum about eating more fish and more nuts and more avocados, the things that are higher in omega-3 fatty acids. Olive oil is one of those prototypical plant-based oils that’s high in omega-3 fatty acids.

(00:37:38):

That’s part of the equation, yes, trying to get more omega-3s because we don’t get enough in our diet, partly because we don’t get enough as a result of the ratio, partly we don’t get enough cause they’re not as available to us. So trying to change that equation in how processed and ultra processed food are created, and making certain that ratio of omega-6 to omega-3 fatty acids is flipped, and really trying to bring it back down to normal. The challenge for this, without spending another hour doing a physiology lecture, which you probably don’t want to hear anyway, but the challenge to this is how those fatty acids are utilized, especially by the brain, how they’re utilized by a lot of other parts of the body in the bloodstream, especially the inflammatory impact, the pro-inflammatory impact of omega-6 versus the anti-inflammatory impact of omega-3. That, in and of itself, is a problem for atherosclerosis or heartening of the arteries, heart disease leading to heart disease, stroke, et cetera.

(00:38:51):

But the real thing that we think is critically important is protecting the brain in a way that you are changing that ratio by reducing the footprint of omega-6 and increasing the footprint of omega-3 fatty acids in the food supply. And again, that’s pretty easy to do if you’re cooking all of your own food and you’re using olive oil and you’re using higher quality oils and fats, lots of nuts and seeds, more seafood, but less seafood than you think, less land animal protein. It will get you to changing that ratio more back to normal, but not everybody has the ability, the time, and also the distribution that we need to be doing with getting food into folks’ hands. We are going to continue doing… We need to process food. We need to make recipes and meals and breads and other pastas, et cetera, but we can do that in a sensible way that, A, feeds the gut really, really well, protects the liver really, really well, and supports the brain.

(00:40:05):

So I think the real crux of that, the real core of that for supporting the brain is in improving the fatty acid ratio, the essential fatty acid ratio. But there’s a lot of other things that went into our discussion with supporting the brain and making sure that we’re not in delivering some other harmful chemicals to the brain that can be in our food supply, cadmium, mercury, other heavy metals, et cetera.

Rob Lustig (00:40:31):

So this ended up being our rubric, the what we now call the metabolic matrix. And then the question was once we came up with that, how can you apply it to an ultra processed food portfolio? How do you turn ultra processed food into healthy food? Is it possible? That was the charge that KDD levied to us, which we took on, and basically took us two years to figure out. So let’s recount for the audience how we did this. What were the steps that were necessary? I’ll start. The first thing we had to do is we had to actually figure out what was in the food to start with. So KDD has a 180 item portfolio. And where did they get their ingredients from? Did they grow them? It’s Kuwait. It’s hot. There are no animals. Okay? They would die.

(00:41:34):

So they make yogurt, they make flavored milks, they make ice cream. Well, where do they get their milk from? Well, they get it from milk powder from New Zealand. Now, did they know what was in the milk powder from New Zealand? Not a clue, but we needed to know because we couldn’t just accept the fact that this milk powder came from New Zealand and was perfectly fine and healthy. Who knows what they were feeding those sheep or cows or whatever else. The bottom line was we had to do a full exhaustive analysis, a biochemical analysis of virtually every single ingredient that KDD used, since all of them had been processed. All of them had come in on ships from somewhere else because there’s no real food in the Middle East anyway because of the heat, because of the climate.

(00:42:35):

So we did that. And what we did was we sent all of these ingredients to a biochemical analysis concern in Des Moines, Iowa called Eurofins, and we actually figured out what was in all the food and we made recommendations to KDD as to whether or not those vendors were actually selling them, what they said they were, whether they were including things that maybe they shouldn’t, and whether or not they needed to find other vendors. So this created a fair amount of political turmoil within the company, and also between KDD and its vendors. So basically you have to have a company willing to put in the work and willing to take it on the chin if necessary in order to be able to do this. And to KDD’S credit and to the CEO and COCO, Sir Mohammad Jaafar and his sister Bahia Jaafar goes really all the credit to this project for doing this. So we found many things in the raw materials that were being shipped to Kuwait that needed to be rethought, replaced, refurbished, re-engineered and reused. That was the first step of the KDD innovative experience.

Tim Harlan (00:43:55):

And the second step is ongoing now with them slowly but surely beginning to redo those recipes for their products. And again, this is a food at an industrial scale. And our society, while I think we all want food to be as local as possible and as close as home to possible, in many ways, the practicality of that and making certain that we’re feeding ourselves is very challenging in what is a very mostly urbanized world, but also in those areas of the world that are not urbanized and have food challenges for a whole host of different reasons. I don’t think that processed food necessarily needs to go away. It just needs to be rethought.

(00:44:46):

And how do you take a product like ice cream and make it satisfying, make it delicious, make it creamy with the right mouth, feel, the right chocolatey flavor, but making certain that you’re reducing the emulsifiers that might be harmful, that you’re reducing the sugar footprint by using other non-nutritive sweeteners that you’re adding in the better quality fats or using better quality fats wherever possible, using chocolate, which many, many sources of chocolate have very high levels of cadmium, using chocolate that’s safer and making certain that we’re improving that chain of command, that of the supply chain of making certain that there’s integrity in the products that are being delivered?

(00:45:39):

It’s a tall order. I think our team has every respect for the idea of a multinational like KDD, or Pepsi or Nabisco or [inaudible 00:45:54]. These are challenging positions for large multinational companies to have. But they are doable, and they’re important. They’re important to making certain, for no other reason, but because of the moral responsibility of me or of a businessman, of the CEO multinational food company, the moral responsibility to make certain that they are delivering the best quality, least harmful food for their patrons. And look, that’s a tall order, and it’s going to take some time to turn the ship that has been steaming along very, very carefully and placidly for a solid coming up on hundred years, since really, in many ways, since Kellogg’s invented the cornflake. So a little over a hundred years now. And can we have better quality cornflakes that taste fabulous and we enjoy just as much if not more, with less harmful ingredients and less sugar, less sodium, better quality oils and fats?

(00:47:07):

Absolutely. Absolutely. It’s entirely possible. Is it a hard work? Yeah, it’s a heavy lift, but it’s a lift worth doing for society. There’s another piece of this puzzle that we also thought was important for KDD and for other multinationals, and that is the integrity of other pieces, as I mentioned of the supply chain, packaging, sustainability for products, impact on the environment. As you said at the top of the hour, Rob, there’s a lot that goes into this. There’s a lot that we have to think about in how we’re going to feed ourselves in the next 25 to 30 years, but those are doable. And our colleagues at the multinational food companies, they have the ability, and they have the money. They really do. And I understand the concept of putting shareholders first, but those shareholders are also your patrons and harming your shareholders is a double-edged sword, right? You might be benefiting their pocketbook, but are you harming their health? And that’s a really important moral and ethical decision that has to be undertaken by our colleagues in the food industry.

Rob Lustig (00:48:33):

Well, my concern is harming our children because they are the future. And if we harm them… And remember, children of the canaries in the coal mine. Whatever it is that we get sick with, they get sick with worse, which of course is why children now have the diseases of aging when they’re five years old, type two diabetes, fatty liver disease. Even cognitive decline we are seeing in five-year-olds because of the food supply. So yes, you’re right. This is not a growth strategy, poisoning your population. This is what they said about tobacco, do not poison your consumers, but that’s what we’re doing now. I have nothing, absolutely nothing against people making money, but they got to make money doing the right thing, not the wrong thing. Okay? That’s where tobacco went off the rails. Well, I’m worried that the food industry does the same thing. They’re making money doing the wrong thing.

(00:49:32):

And the point is they can make money doing the right thing. Now, does it mean a change in what they’re doing? Absolutely. Of course. The question is how do they do that? What’s the roadmap for being able to do that? And that’s basically what we did in this paper that just got published in Frontiers in Nutrition called the Metabolic Matrix. Everyone can find it,. Just go to your web browser and put in The Metabolic Matrix, and it will come up. Frontiers in Nutrition, March 30th, Dr. Harlan is the first author. I am the last author. So example of what we did, sweeteners. There’s something wrong with every sweetener. Obviously there’s something wrong with sugar. We just discussed how fructose in interferes with AMP kinase and mitochondrial function. There’s something wrong with all the other sweeteners too. There’s something wrong with sucralose. It causes alterations in the microbiome and causes leaky gut.

(00:50:36):

There’s something wrong with the spartan. It gets turned into toxic byproducts, which have actually been associated with cancer, and possibly dementia as well. There’s something wrong with monk fruit because it still generates an insulin response and still drives chronic metabolic disease. There’s something wrong with Stevia for the same reason. The question is how do you sweeten a product and still have people who want to consume it and yet it still be healthy? This was perhaps our biggest challenge in this exercise with KDD because they’re making a lot of things that are sweet. So how do you do that? The first thing we learned was that if you look at all of the different items that are out on the market today, that are no sugar added, no one ever buys them a second time. They’re sweet, but they’re not very interesting. And there’s a big difference between being sweet and being interesting, being interesting to come back a second time.

Tim Harlan (00:51:44):

I don’t know, Rob, I think you’re sweet and you’re interesting.

Rob Lustig (00:51:46):

Well, thank you. So what we learned was you actually have to provide that reward, that reward signal. And the non-nutritive sweeteners don’t provide that reward signal. That’s actually been shown on functional MRI. So what we did was we determined what the upper limit of sugar availability in any given food should be in order to both be saleable, palatable, and at the same time, not trigger a hepatic insulin resistant response. And we came up with one teaspoon per serving, one teaspoon. Now, one teaspoon is still rewarding, but not enough to say sweeten an ice cream. So we had to then look at the possibility of a sugar extender. And what we came up with, and it looks actually like there’s some metabolic benefit to it, is a new sugar. It’s actually a naturally occurring sugar. It occurs in strawberries. It occurs in mangoes. Nature made it, and it’s called allulose.

(00:53:04):

And there’s a lot of products with allulose out on the market today. It is about 12 times as expensive as sugar right now, which is why you don’t see it very much. But actually, when you look at the biochemical profile of allulose, it actually looks relatively benign, and it actually might, in some cases, even be beneficial. It lowers LDL, raises HDL, might improve cardiovascular parameters. Clearly we need more data on these to be absolutely sure of this, but no one’s found the problem with it. And it is an epimer of fructose. It is basically very, very similar to fructose and binds to the same receptors. So we found that we could use allulose as a sugar extender, and that is actually what we’re proposing to KDD as an option. However, we found that there’s a political consideration. The Gulf Cooperation Council, which determines what actually gets into the country, hasn’t yet approved, even though the European Food Safety Authority has, and even though the FDA has. So we’re working the political minefield in the Middle East as well, and working on the various political structures in the country to try to make this happen.

(00:54:26):

So this has been a real revelation in terms of how one brings a food to market, and I’ve learned a tremendous amount during this exercise. And I think we’ve done something really worthwhile and really good.

Tim Harlan (00:54:42):

Yeah, it’s been really fascinating and super interesting. I think the very cool thing from my end and what I do is this is now bleeding over into how we are educating healthcare professionals, as well as food service professionals in the programming that we use, the culinary medicine program that’s used across the country at currently about 60, 65 academic medical centers that are teaching their medical students to cook, teaching their nursing students to cook, teaching their faculty to cook in a way that helps them understand food better and they can change the conversation with their patients. Doing the same thing now with culinary schools, helping culinary schools train future food service professionals, chefs and food service professionals, many of whom will end up in the larger food packaging industry, oftentimes. How do we help them understand making the healthiest possible food? When I’m talking with patients who are drinking sugar sweetened beverages, that soda, that 16 ounce canned bottle of soda is going to have somewhere around 14 to 16 teaspoons of sugar, most of which is fructose mocha, most of which is fructose.

(00:56:08):

And I often say to patients, “Look, do you like iced tea?” Almost all of us really like iced tea. It’s kind of an American cultural thing. “Go home, pour yourself a 16 ounce glass of iced tea, put some ice in it, and then try and get 16 teaspoons of sugar to dissolve. You can’t even get it to dissolve. And the problem is that there’s just too much sugar in that sugar sweetened beverage where really it probably only needs one teaspoon for every cup to 12 ounces, cup, cup and a half serving for it to be sweetened enough for most of us.” So there is a way forward. It’s just about making certain that the food is not being manipulated in a way that, as Dr. Lustig said, helps reinforce our desire for that food. So it’s doable and easy to do, but it’s a heavy lift. It’s a big challenge.

Rob Lustig (00:57:08):

Without question. I want to sort of close with a positive uplifting message here basically to reiterate what you just said. That is when I went to medical school, I didn’t learn anything about nutrition. And my best guess is, Tim, you didn’t either, not in medical school. You learned it elsewhere. In fact, only 28% of medical schools in the United States even have a nutrition curriculum. And of those, the number of contact hours for nutrition is only 19.6 median. When you think about medical schools being 6,000 contact hours of training, okay, 19.6, which is like 0.001% to solve 75% of the pathologies that we are taking care of seems a little lopsided. In fact, your doctor doesn’t know anything about nutrition because medical school never thought that was part of the important curricula. They figured that was for somebody else to do. The fact matter is it is for us to do, and we need to understand that food is medicine, but that food can also be poison.

(00:58:24):

And it’s not about calories. It never was. Yes, we needed to feed a destitute population. Yes, we had problems with malnutrition and marasmus and [inaudible 00:58:37] in the past, but the bottom line is that’s not what we have today. What we have today is metabolic disease due to food that is poison. And we have to understand, as doctors and scientists, how to mitigate that and how to teach our patients how to mitigate that. And that is what I think is [inaudible 00:59:02] of the work that we have done together to create this rubric. Protect the liver, feed the gut, support the brain. Any food that does all three is, by definition, healthy. Any food that does none of those three is, by definition, poison. And any food that does one or two, but not all three is somewhere in between. And we need to look at food in that light.

(00:59:28):

And when we do that, we will basically start saying no to the processed food industry. And then they will get the message, and then they will fix it. Years ago I met with an executive from a famous food company who will remain nameless for the moment, as will the name of the gentleman, and he told me directly straight up, “We can change. We’ve changed before. We had to change back in the seventies when we went low fat. We can change again with two provisos. We won’t go it alone and we can’t lose money.” Now, 10 years ago, both of those were non-starters. Today, we now have the roadmap for the entire food industry to be able to change and the proof that you don’t have to lose money, in fact you will make money. So I’m hoping the work that we’ve done together, the work that we’re promoting will ultimately be the signal, the sentinel to the food industry, that it’s time to get on board and fix the problem.