Can A Food Product Scoring System Improve Our Diet And Eliminate Nutrition Confusion?

Mark Hyman, MD

Dr. Mark Hyman is leading a health revolution—one focused on using food as medicine to support longevity, energy, mental clarity, happiness, and so much more. Mark Hyman, MD is a practicing family physician and an internationally recognized leader, speaker, educator, and advocate in the field of Functional Medicine. He is the founder and director of The UltraWellness Center, Founder and Senior Advisor for the Cleveland Clinic Center for Functional Medicine, a fifteen-time New York Times best-selling author, and Board President for Clinical Affairs for The Institute for Functional Medicine. He is the founder and chairman of the Food Fix Campaign, dedicated to transforming our food and agriculture system through policy.

He is a co-founder and the Chief Medical Officer of Function Health. He is the host of one of the leading health podcasts, The Dr. Hyman Show with 150+ million downloads. Dr. Hyman is a regular medical contributor to several television shows and networks, including CBS This Morning, Today, Good Morning America, The View, Fox, and CNN.

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Full Transcript

Automatically generated. Please forgive any typos or errors in the following transcript. It was generated by a third party and has not been subsequently reviewed by our team.

Introduction:
Coming up on this episode of the Doctor's Pharmacy.

Dr. Dariush Mozaffarian:
It's not a either or. We have to do it all. We're not happy with the current food system, but we have to help people make better choices and navigate within it, and we have to radically reinvent the food system at the same time.

Dr. Mark Hyman:
Welcome to Doctor's Pharmacy. I'm Dr. Mark Hyman. That's pharmacy with [inaudible 00:00:24] place for conversations that matter. And we're going to get into some deep things that matter to all of us, which is how do we choose the foods we eat, and what is it based on, what are the scientific controversies that exist now around certain things in nutrition? And we have an amazing guest today, someone who's been on the podcast before who's a good friend of mine, a colleague and someone who's working in Washington right now aggressively to change overall food policy from food is medicine to regenerative agriculture, and he's in the trenches. He's also a cardiologist. He was the dean of Tuft's Friedman School of Nutrition Science and Policy, but stepped down temporarily to actually work on policy in Washington, which is really important. So I think that speaks to who he is.
He's published over 500 scientific publications on diet, nutrition, and I've read many of them, not all of them. He's just so prolific, I can't keep up on obesity, diabetes, heart disease, and how we create evidence-based policy approaches and innovations to get rid of all the diet-related disease we have in the United States and around the world. And he's been in lots of advisory roles, and he's been named by Thompson Reuters as one of the world's most influential scientific minds, and he certainly has influenced me in many ways. And I think he's a real icon and leader in the space of nutrition and real change.
Not just sitting in an ivory tower, but on the ground trying to make real change. And we're going to talk about some of the things that he's done and some of the things that we need to think about in terms of how we frame our choices about what to eat and how we understand what whole foods are, what ultra-processed foods are, how we can evaluate different foods across the spectrum of all the choices we have. And I'm super excited to have Dari back on the podcast. So welcome.

Dr. Dariush Mozaffarian:
Thank you so much, Mark. You laid out why this is such an important topic. We're literally dying from food, and we've got to fix it.

Dr. Mark Hyman:
Yeah, it's true. Now, one of the things that I've learned, and I've written so much about diet nutrition, and I've spent 40 years studying nutrition. My first course was at Cornell in, embarrassed to say, 1979. I'm so old. And it was Colin Campbell who was a professor of nutrition at Cornell then. And I've been studying ever since. I read Roger Williams' book, Nutrition Against Disease in college, and it really influenced me to think about how we use nutrition in medicine. And as I became a doctor, it became a big focus for me. And I can say after 40 years of this, I'm still freaking confused about a lot of stuff, because the way we do research in nutrition is challenging because it's not like you can take 10,000 people, lock them in a laboratory, give them a certain diet, and then take another 10,000 people, lock them in a laboratory, give them a different diet and study them for 30 years in a laboratory.
That would be the way to do it and measure everything, but we just can't do that. So we have imperfect evidence, and we have to make conclusions from those pieces of imperfect evidence. So I'd love to talk to you first about why people are so confused about nutrition. One day eggs are good, one day eggs are bad, one day eating carbs are great, and we should have six to 11 servings of bread, rice and pasta, and then we find out they're not so good to have all this rice and pasta, bread. Why are we so confused, and what are the limitations of research? How do we know what we know going from randomized control trials to population studies to animal studies to in-vitro studies? Tell us a little bit about how we know what we know in nutrition, and how you've come to the conclusions that we can actually start to make choices and decisions about?

Dr. Dariush Mozaffarian:
Right. Yeah, no, great question and a good place to start. So first, people are confused, and even scientists are confused about some of the evidence, because the science is changing. I think that's the first and foremost reason that people are confused, because the science of what we thought 30 years ago, it has shifted over time. There have been some real shifts over time. There have been some things that have stayed the same, but there are some things that have changed. And that's for a few reasons. First and foremost is because nutrition sciences is really, really young science. From roughly 1932 when vitamin C was the first vitamin ever isolated and synthesized, that's 90 years ago, the first vitamin ever isolated and synthesized. From 1932 to about 1980, the first 50 years nutrition science focused on vitamins and focused on calories and getting enough calories, and agricultural policy, food policy, focused on those things because that's what the science was.
How do we get enough vitamins to people, and just a handful of vitamins, the vitamins that were known, vitamin D, vitamin C and niacin and so on, and how do we get enough calories to feed a growing world population, a population where more people were born in the last century, about four and a half new humans were born. More people were born in that century than in all the prior human civilization, human history combined. So we had a population explosion. So that's kind of what the science focused on from 1930 to 1980, was vitamins and calories. And it's really starting around the '70s with some early studies, but really starting around 1980 in the first US dietary guidelines focused on chronic diseases in 1980, that we started thinking about in a serious way nutrition and chronic diseases, complex diseases that take years to develop, heart disease, stroke, atrial fibrillation, diabetes, obesity, cancers, and now even more recently, brain health, gut health, autoimmunity, inflammation, autism, many diseases that may be related in some ways to nutrition.
And so that's just been 40 years we've been really studying that seriously, and so the science has changed. Now, I think it's a good question is, has the science changed more or more quickly than other sciences? I'm a cardiologist, and so I think about how cardiology has changed, and the science of cardiology has changed dramatically in 40 years as well. And there's a lot of things that we used to say you couldn't do, and have changed. I'll just give you one example. When I was an intern at Stanford in internal medicine, my first year we had a patient with heart failure come in with a really rapid heart rate, and I read some studies that said patients with heart failure might benefit from beta blockers, and I said, "That's really interesting," and I went to my senior doc and I said, "Can we try a beta blocker in this patient?
And he said, "Oh, no, no, no. We know very well that the adrenaline response is needed for compensated heart failure. If we give a patient a beta blocker, they're going to get sick, they're going to die. We shouldn't do that." And then five years later in the middle of my cardiology fellowship, five years later, several randomized control trials had been published that giving beta blockers to patients with heart failure lowers death, lowers heart attacks, improves the heart function. And then we were providing beta blockers, and my different senior physicians were saying, well, of course we know that beta blockers and excess [inaudible 00:07:27] function is detrimental to the heart and [inaudible 00:07:31]-

Dr. Mark Hyman:
They're backpedaling.

Dr. Dariush Mozaffarian:
And so that science radically changed. Look at physics, physics not only went from Newtonian mechanics to quantum mechanics to general relativity, there's still fights about general relativity and quantum mechanics. They don't work together. Gravity and quantum mechanics don't work together. And-

Dr. Mark Hyman:
Physics is way more simple than biology.

Dr. Dariush Mozaffarian:
Yeah. And over the last 30 years, dark energy's been discovered, dark matter has have been discovered. We don't even understand 95% of what's in the universe. And so the science is really... So if you look at any science, genetics, physics, medicine and nutrition, science changes. I think what's different, to get to the crux of your question, is that when the science of physics changes, or when the science of beta blockers for heart failure change, or when the science of chemotherapy for a certain cancer changes, most people don't know what had changed, and if they know it changed, it doesn't affect them personally that day, but when the science of nutrition changes and we go from 1992 food pyramid with refined grains at the bottom of the food pyramid to today saying, refined grains aren't good for you, that's very personal, and that really changes daily decisions. And so I think what's different is-

Dr. Mark Hyman:
Yeah. Most people aren't trying to figure out whether to take a beta block or not every day. They're trying to figure out what to eat every day.

Dr. Dariush Mozaffarian:
Yeah. So I think nutrition science is changing, and we have to accept that, and accept that we know more, it's better, it's definitely better, but there are still things we don't know, and there are things that have changed, and we have to kind of say, Mia Culpa, we were wrong as scientists for what we said 30 or 40 years ago.

Dr. Mark Hyman:
And I know one of the things you're really focused on, Dari, and I've been part of the conversations and trying to help with this, is to try to establish a new National Institute of Nutrition. Most other countries have it. We don't. We spend almost nothing on nutritional science. We spend $6 billion on cancer, and we spend billions on Alzheimer's and heart disease, and literally almost nothing on nutrition studies, which are really underlying many of these conditions, or either a contributor or a big cause. So it's really embarrassing, and I know you're working hard to change that, and you really are moving the needle. Actually just as an aside, I was talking to the CEO of Nestle Health Sciences and about Nestle helping to advocate for a National Institute of Nutrition, so we're going to push this forward. I think we've got to have it happen, because we just have such a lack of really well-funded large trials that are hard to do.
Because it's hard to do these randomized trials on people. It's hard to control diets. It's hard to do it with, we call it free living humans who have choices to go, oh, you give me eat this, but then at night they go have a pint of Ben & Jerry's, it kind of screws it up. And then observational studies is where we also try to learn what might correlate. With smoking and lung cancer, we found there was a big correlation, but it was a 20 to one risk as opposed to nutrition studies, which are harder to do, and there's always confounding factors, what are they eating in addition to whatever the bad food is we think is bad, or what are they not eating that they need to eat. So it's very complicated, and so we kind of have imperfect evidence, but with that, we still have to make choices, we still have to decide how to guide people on what to eat, we still have to develop dietary guidelines, we have to develop ways to score foods that people and consumers can use to make their choices and pick better foods.
Now, in the perfect world, would we all be eating whole real food that's unprocessed, that's high in nutrients? Yes. But that's not a reality right now in the world, because much of the food we eat is processed in some way, is industrial food, and I don't think we're going to get away from that. So in the service of trying to help people, I think Tufts, which is by the way, as far as I know, the only school of nutrition science and policy in the world, has developed a scoring system that try to improve on old nutrition scoring systems. Around the world, there's ways of scoring foods and whether they're good or bad for you, and how good and how bad, but they were imperfect, and Tufts spent a lot of time, energy, and money to develop something called the Food Compass, which many of you may not have heard about, but it's an important step in trying to look at food from a more nuanced perspective.
And I want to talk to you about why this is so important, and also to explain a little bit about the methodology. Because I think you worked on an algorithmic model with nine different domains of things you're looking at from nutrient ratios to vitamins and minerals to food-based ingredients, additives, the level of processing, the fats that were in there, the fiber, protein, the phytochemicals, which no one had really looked at before, what's the value of all these phytochemicals. There are 54 different things that were kind of looked at. Now, based on that, you developed a scoring system, and I think let's just talk about why it's important to do this, what it's used for, because there's countries, for example, like Latin America in Chile where they put black box warnings where it says saturated fat or sugar or calories, it's bad, and there are limitations to that, because not all saturated fats are bad.
I don't know if you saw, Dari, the article in the New York Times about this dolphin research with the navy where they were looking at this C15 saturated fatty acid that's found often in dairy that has enormous beneficial effects for our biology, whereas other saturated fats may not. So I think I'd like to have you unpack that a little bit.

Dr. Dariush Mozaffarian:
Yeah, you covered all a lot of ground. And I think let's start with the evidence, because that leads into Food Compass too. I think the way I think about the evidence for nutrition science is, because we don't have usually any single study that can prove something, whether it's a trial or an observational study, it's important to triangulate between different types of studies. And so you want to look at long-term prospect of observational studies of disease outcomes, you want to look at randomized trials, look at risk factors for those diseases. So for example, you might look at a long-term observational study of whether people develop diabetes, and then you look at a randomized trial of glucose or insulin or hemoglobin A1C, and then you hope you can also get a randomized trial of onset of diabetes, which is harder and more expensive, and then you triangulate and you say, do those three types of studies show the same directionality and show the same consistent results?
And there are some things where we have actually all three of those pieces of evidence. We have randomized trials of disease outcomes, observational studies of disease outcomes, and randomized trials of intermediate risk factors. And probably the best example is the traditional Mediterranean diet. That's been just in all the studies ever it's been looked at, it's been shown to be better for health. So I think even with limited evidence, there are ways to triangulate. Another example is sugar and sweet beverages and weight gain. We have all the evidence from all the different types of studies showing that sugar and sweet beverages are bad for weight gain. So I think there is consistency for certain things. So food rating, why would we want to rate foods?
So it's not that common in the United States, although there are grocery stores that do it. And so Hannaford's here in New England uses Guiding Stars, Kroger has just launched OptUP, Walmart had a, I think it was called Great for You or Better for You system. Those were actually all food rating systems. The government has actually proposed, the Food and Drug Administration has proposed a new kind of definition of healthy, which is a proposed rule, which is actually a food rating system. So that should come out in the United States in the next year or two when the rule is finalized. But while the United States is still, I think, behind other nations, its big time in other countries. And so in Europe in particular, in the United Kingdom, in Australia and New Zealand, all of them have either mandatory or voluntary, but widely used front of pack food rating systems.
And they use something called either Nutri-Score or Health Star Rating are the two most common ones. And what those systems do is, they take seven or eight or nine nutrients like salt and sugar and some vitamins and protein, and sometimes a couple of food ingredients like the amount of fruits or vegetables, and they kind of put them together in a score to give an overall summary rating to put on the front of package. Health Star Rating, you get a certain number of stars, Nutri-Score, you get a A, B, C, D, or E. And that is intended to help consumers make a easier choice, rather than trying to look on the back of the pack and figure out all that nutrient information, ingredients, to just a single-

Dr. Mark Hyman:
You need a PhD for that.

Dr. Dariush Mozaffarian:
Yeah. You get a single summary score. And then as you described really well, other countries, especially in Latin America, Chile, Brazil, Mexico, many other countries are taking a different approach. Their food rating systems just rate single nutrients one at a time. And so if a product has too many calories, it gets a black box warning label, too much sugar, black box warning label, too much salt, too much saturated fat, and even too much total fat in some cases get a black box warning label. So all those systems have some pros and cons, but I think they have some significant cons. And so we said, look, can we look at what those systems do and what they do well and add and make them better?
Because they're being used, and they're being used not just for consumer communication, but also for industry targets. And so Nestle globally has announced that they're going to report every year now on their entire portfolio using Nutri-Score. So they're going to try to improve their portfolio and reformulate their products following Nutri-Score. So these food rating systems are kind of a roadmap of where you want consumers to go, where you want industry to go. And the destination you get to with the roadmap is only as good as the accuracy of the roadmap-

Dr. Mark Hyman:
As the roadmap. The roadmap. Right.

Dr. Dariush Mozaffarian:
And so Nutri-Score is pretty good. I don't want to say negative things about Nutri-Score, but it's not great. It has some limitations. And so if we're going to go down that road, we're going to improve the food system, but maybe not improve it in the direction we want. And so another use of these profiling systems is for investors. Investors are starting to demand metrics for companies to be doing the right thing, for example, around sustainability and carbon footprints, but increasingly there's recognition that investors are saying, look, we're also going to demand nutrition metrics. If I want to invest in a big multinational food company or in a farm or in a supermarket, I want to know are they improving the public's health, or are they worsening the public's health, and how do you do that without a scoring system? So it can also be used for investors. So there's a lot of uses for these scoring systems. Online grocers is another example-

Dr. Mark Hyman:
Now, they're not dietary guidelines. They're not meant to be dietary guidelines like the US Dietary Guidelines. They have a different use, right?

Dr. Dariush Mozaffarian:
That's a great point. So let me just give the last example, and I'll get to that. So online grocers now are trying to decide, if I can go to your employer and get your employer to give a wellness benefit for you to buy healthier foods... Many employers pay 20, $30 a month for you to have a gym membership. Employers are starting to say, I'm going to pay 20, $30 a month to buy healthier foods. If you want to do anything beyond fresh fruits and vegetables, you need a rating system, what would the employer pay for, and what would they not pay for. You need to have some ratings. So that's another use.
So there's all these potential uses. You mentioned a really important point, Mark, is that these are not dietary guidelines, and so you're not supposed to use these rating systems to figure out your entire diet. As two examples in Food Compass, asparagus scores a 100, which is a perfect score, raspberries score 100, which is a perfect score, if you ate a diet of asparagus and raspberries and that's it, you'd get sick-

Dr. Mark Hyman:
You'd be nutritionally deficient over time-

Dr. Dariush Mozaffarian:
That's not a great diet. So they're not-

Dr. Mark Hyman:
And your urine would smell really funny.

Dr. Dariush Mozaffarian:
So what you're supposed to do for these systems is, when you're making a choice between usually similar products, if you're in the yogurt aisle and you're looking at this long aisle, if you're in the cereal aisle and you want to buy cereal, if you're in the bread aisle, if you're looking at energy bars in the airport [inaudible 00:20:24]-

Dr. Mark Hyman:
Yeah. They're not all created equal.

Dr. Dariush Mozaffarian:
Look at all those energy bars, and they all have marketing claims and packaging claims. It's to help you within whatever your goals are. If you're a vegan and you're never going to eat red meat or eggs or dairy, but you want to choose healthier grains, it can help you do that. If you're a paleo person and you're only going to focus on paleo diet, it'll help you within your dietary choices. So that's the goal of these rating systems, especially, especially for packaged foods. That's really where there's marketing claims and all these other things. And so that's the goal, and [inaudible 00:20:59]-

Dr. Mark Hyman:
That's really important. What you just said is super important, Dari. I just want to highlight it before you go on. Because when you go into the store, it's a shit show. You're so confused by all the dietary claims, and most of the problems with nutrition labeling has been what Michael Pollen called nutritionism, which is reductionism. And this has led to SnackWell cookies and low fat yogurt with tons of sugar and things that are really bad for you. Your Yoplait yogurt which is sweetened with sugar is worse for you, more sugar. The Yoplait thing is amazing. You've got basically a yogurt that you think is healthy for you that has more sugar per ounce than a can of soda. So that's just kind of out there, and you don't have a way of differentiating for the average person. And I do this for a living, and I still get like, oh, what am I going to pick? So it's tough. So it has a big value to create this for consumers.

Dr. Dariush Mozaffarian:
Yeah, I think it's very valuable. And I think you raised an important point. In the ideal world, we'd all grow our food in our own gardens and have our own chickens and livestock and regenerative agriculture, and then cook three hour meals and sit at a table and eat slowly and mindfully. And maybe we can get there someday. Maybe that's a goal.

Dr. Mark Hyman:
Working on it.

Dr. Dariush Mozaffarian:
But today there are tens of millions of Americans who are food insecure and are just struggling to get the next meal on the table. There are billions of people in the world who can't afford a minimal healthy diet with minimally processed foods. We have a faculty member, Will Masters, who's written that, and that's entered the United Nations scoring, that there's 2 billion people that can't afford a minimal healthy diet. So there's lots and lots of people who need to go into a grocery store, and they are going to buy and need to buy for their time and cost and opportunity processed and packaged foods. And so we can't have this sort of privileged view that we should only be eating grass-fed livestock beef from my local farm and organic fruits and vegetables in season and ancient whole grains that are sprouted with extra virgin olive oil-

Dr. Mark Hyman:
Sounds good to me, but it's tough.

Dr. Dariush Mozaffarian:
... From the right farm in Italy. It is perfect, but it's a privileged view to say all people have to eat that way, and must eat that way. So we have to meet people where they are. If someone's going to get breakfast cereal for their kids, if someone's going to get dessert, if someone's going to go get ice cream for their kids, which is totally fine, if someone's going to get candy for Halloween, can we help people make a healthier choice? So that's the goal of these food rating systems.

Dr. Mark Hyman:
I think it's really helpful. And I think what's different from my perspective about the Food Compass system is that, it tries to not be so reductionist. It's still reductionist to a point, but it looks at 54 different determinants, not just salt, sugar, saturated fat, calories, which is what most of the rating systems are relying on, and they're looking at more of the complex mixtures of foods and complex products that are more than one thing. And there's still limitations. There's no knowns. We know that refined sugars and flowers are bad. There are things that we know that we really maybe weren't able to include in the calculations, because there's no data like, what's the glycemic index for a load of foods, and when you eat it, and what's your microbiome, and what's your insulin resistance status, and how does it affect you.
Because the same food can affect different people in very different ways, depending on your own unique metabolism and biochemistry and microbiome and genetics. So none of that we can really know well right now. Maybe at some point in the future, we can. And then there's things we don't know. We just don't know what we don't know, which are kind of... For example, phytochemicals, we didn't even know there were phytochemicals that were important. They were called secondary compounds, or thought were not important, but turned out I think maybe to be the most important things in the food we're eating. So doing this is an iterative process. It's not like, okay, this is the definitive thing, and we're going to say this is what everybody should be doing. We need to so say, okay, we're going to keep improving it. And I think that's the beauty of the Food Compass, is its meant to be iterative.
And we talked a little bit before the podcast about how there's another version coming out that learns from what the limitations were. So I think maybe you can talk about the way you developed it, these 54 attributes in the nine domains, and maybe dive into some of the strengths and the limitations that you even talked about in the paper, for example, how do we know if minimally processed whole grains are as good as whole grains, and does it matter? Is it good still? And so there's things we are trying to figure out.

Dr. Dariush Mozaffarian:
Yeah. No, you gave a perfect summary of our approach. And so first this is research. This is science. We're trying to build a better mouse trap, and it's iterative. And what we've done is developed the system and published two papers on it, and now based on just two papers and that work, we're improving the system further. And so what we did is, first get a group of great diverse scientists together, economists, people who study global nutrition, people who study phenolics and phytochemicals, epidemiology, physicians, a great group of scientists together and to just sit down and say, what are the things that we think are the top scientific principles for rating foods? And we want to move beyond fat and calories and saturated fat and sugar and salt as the top determinants, which are basically the top determinants in Nutri-Score and Health Star Rating. There's some other things, but those are the top determinants.

Dr. Mark Hyman:
And by the way, Dari, that's what leads food companies being able to manipulate foods and tile up or down ingredients to create junk food that looks a little bit better, but isn't, like SnackWell cookies. That was a great example.

Dr. Dariush Mozaffarian:
Right. And we also consciously wanted to say, whatever we create, we want it to not be able to be gamed by the food industry. You really have to make the food healthier. So we ended up creating a more holistic system. It's more complicated, but it's more holistic. And so it has nine areas or domains that are all rated first, and then those domains are summed. And that domain approach is really important, because it means that even if food's terrific and amazing in one domain, but it's really bad in the other eight, it's going to get a bad score. And so that means food has to holistically be good across multiple things to get a good score, and holistically be bad across the things to get a bad score. And if it's in between and a mix, it gets a middle score. And-

Dr. Mark Hyman:
So if you put all these phytochemicals in Coca-Cola, it doesn't make Coca-Cola good, right?

Dr. Dariush Mozaffarian:
That's right. It's not going to change the score very much. And so the different domains included things like vitamins and minerals, which makes sense, but also food ingredients. We had a lot of data on food ingredients. We included processing. So this is the first time that processed-

Dr. Mark Hyman:
Food ingredients, talk about the food ingredients. Go a little deeper, because I think food ingredients was interesting. You have food-based ingredients, additives. What are the things you looked at?

Dr. Dariush Mozaffarian:
Well, let me let me go through the domains, and then maybe touch on, get to the specifics. But yeah, so processing was included. And so things like the NOVA classification of ultra-processed foods. We included additives like not only added sugar and salt, but we think we should score artificial sweeteners, artificial colors, other things. Let's talk about what we didn't include. We didn't include calories. A food shouldn't get dinged because it has calories. That doesn't make any sense. All of them have it. We didn't include total fat. Total fat is not useful for health. And we didn't include saturated fat by itself. No food gets a negative point just for having saturated fat. We included the ratio of unsaturated fats to saturated fats. And we included phenolics, flavanols, carotenoids, we included trace lipids, things like omega-3s and trans fats and other things.
And so overall about, like you said, 50 attributes across nine domains, and then we combined that into a linear score that rates every food from one to 100. And a food that gets a 50 versus a 55 isn't that different. You don't want to be micro-judging food. So we roughly said foods roughly that get a 70 or above are probably pretty healthy and are foods to be encouraged based on our findings. Foods that get 30 or below are foods to be minimized. Not never eaten, but minimized. Those are things you probably don't want to eat a lot of. And then foods kind of in between 30 to 60 are foods to be eaten in moderation. And of course probably higher scores are a little bit better than lower scores, but roughly foods in that middle range to be eaten in moderation. And so that's kind of the overall scoring system. And once you make the scoring system, then you apply it. So first, and I think this is really important, we developed [inaudible 00:29:47]-

Dr. Mark Hyman:
The other thing you did was the ratios, which was I think interesting. When you looked at nutrient ratios, which I think is something that people don't understand, fiber and carbohydrates, or sodium and potassium, or the amount of unsaturated fats and saturated fats, and omega-3. So its more nuanced look at everything.

Dr. Dariush Mozaffarian:
Yeah. So actually the single most predictive... Because we looked at how the domains predict healthfulness in people in a second paper, which we can talk about, but of the nine domains, if you look at the nine domains separately, one of the most important predictive domains for the healthfulness of the food was this ratio domain, which just included three ratios, the ratio of unsaturated to saturated fat, which gives a rough measure of overall fat quality, the ratio of carbohydrate to fiber, which gives a rough measure of overall carb quality, and the ratio of sodium to potassium, which gives a rough overall measure of mineral quality. The reason the carb to fiber ratio is important, Mark, is because if you just look at sugar, you're going to miss refined starch.
And so one of the big, big to me missing holes of the current systems is, there's no negative scoring for refined starch. And so if you get a cereal or a cracker or an energy bar or white bread that's just 100% starch, you and I know starch is glucose. Starch is 100% glucose. The test standard for glycemic index is white bread. Glycemic index of 100 is white bread-

Dr. Mark Hyman:
Someone's [inaudible 00:31:20] bread.

Dr. Dariush Mozaffarian:
It's the worst. And so that's the test standard-

Dr. Mark Hyman:
It's worse than sugar. Right.

Dr. Dariush Mozaffarian:
... Is white bread. For glycemic index, it's worse than sugar. So we really wanted to give negative points to refine starch, and not let refine, processed starchy products, grains get a free pass. So that ratio domain was very important. And the sodium to potassium one is also I think important, because we know salt raises blood pressure. We know salt is bad. There are some salt skeptics, but it's been clearly documented, including in randomized trials of stroke risk, but potassium counters that, potassium counters that. And so if you have a product that has 300 milligrams of sodium and 10 milligrams of potassium, it shouldn't get the same score as a product that is 500 milligrams of potassium. And potatoes are kind of a good example of that. Potatoes have a lot of starch, but they also have potassium, and so you should credit that potassium. So we could go into all the details of all the domains, but we really tried to be careful and holistic. And what I want to emphasize too is, we didn't look at the products and say, how should this product score? Let's score it.
We created the system and then said, okay, now that we've created it, let's see how it scores on actual foods, and let's see how it compares to other nutrient food rating systems that are out there, and let's see if it predicts health outcomes if people actually followed this system. So that's science. We didn't prejudge or pre-guess what would happen, we set up the system, we published our paper transparently, we published the whole algorithm transparently so people can look at it and give us feedback.

Dr. Mark Hyman:
Yeah, it's super helpful, and I think it's a big advance, and there's still a lot to do and a lot to learn. And I think as I was going through it, people have pushed back on some things. The things that caught my attention were things that, from I would say I'm maybe more of a nutrition purist, because I thought, what's optimal for humans, is how do we look at, for example, the quality of fat. So you have a unsaturated to saturated fat ratio, but what is the unsaturated fat? Is it omega-3s? Is it maybe more beneficial seed and bean oils like canola and soy, or maybe ones that maybe have shown to be more harmful like corn or peanut? So there's little things like that, and then cholesterol was the other thing I was wondering about why that was included, because of the newer data that show that it doesn't seem to have a huge impact on cardiovascular disease.
So there were just things that were interesting. And then I think there's also, we talked about this earlier, was that there's not a lot of good databases on the glycemic load or index of food. And that, by the way, is variable depending on the person. So that's hard to include in something like this, which I think you try to do with a carbohydrate fiber ratio, but there are all these challenges in the research, so it's clearly some stuff we have to try to figure out how to layer on top in some way or refine, or when there's more data come in, to kind of update it.

Dr. Dariush Mozaffarian:
Yeah. And so first what did we find once we did it? So we published two papers, and the first paper we compared Food Compass to other food rating systems, particularly Nutri-Score score and Health Star Rating, which are, again, pretty good. They aren't terrible. Pretty good systems used around the world. And we found on average, it works better. On average, it works better. In particular, our scoring system gives really low scores to refined grain products even without added sugars, and in those scoring systems, refined grain products that don't have added sugars get great scores. And you think about a non-branded cornflakes cereal, it's just corn starch. Not corn, it's just corn starch. It's 100% glucose. It's glucose in a box, but it doesn't have added sugar, it doesn't have a lot of fat, it doesn't have a lot of salt, it gets great scores on Nutri-Score and Health Star Rating. In Food Compass, it gets one of the worst scores, because it's refined starch.
White bread, pita bread, bagels get very low scores. Low fat deli meats, low fat processed meats like baloney got good scores on those systems. They're low fat. They got credit for being low fat. They get terrible scores on our system. Low fat coffee creamers, low fat salad dressings, all these low fat products got low scores on our system because they're processed and have a lot of starch in them. So overall, it worked better than the other systems. And I should of course mentioned since we didn't give negative points to total fat, and we gave positive points to unsaturated fat, nuts and seeds and oils scored really well.
And so one of the big criticisms of Nutri-Score, for example, is extra virgin olive oil scores really terribly, and nuts and seeds don't score that well.

Dr. Mark Hyman:
It doesn't make sense.

Dr. Dariush Mozaffarian:
And there's been olive oil growers in Europe have actually sent letters and gotten angry and said, why are you telling us extra virgin olive oil is an unhealthy food? Those foods score over 90 on Food Compass. So extra virgin olive oil, I think scores are over 90. Nuts and seeds score over 90. Most seafoods score really, really well, because they have omega-3s. We did account for omega-3s, Mark. So seafood scored really-

Dr. Mark Hyman:
Yeah, most processed foods don't have olive oil in it, right?

Dr. Dariush Mozaffarian:
That's true. That's true. Yeah. So those are the positive things. And then in our second paper... So it worked better than Nutri-Score score and Health Star Rating, we think. Our second paper then, I think we did something really important. We said, okay, that's just the ratings, but what if somebody actually followed it, how would it affect their health? And so we looked at a nationally representative sample of almost 50,000 Americans who had been followed for many years, and who had all reported what they'd eaten down to the product level, very specific products of what they had eaten, and we scored all the foods they had eaten, and we gave each person an energy weighted Food Compass score. So based on the Food Compass scores and the calories of all the items you ate, what's your energy weighted Food Compass score, and we looked at how that predicts health outcomes.
And we found on average for... Again, Food Compass goes from one to 100. We found on average for every roughly 10 point difference in the individual's Food Compass score, they had lower obesity, lower hemoglobin A1C, lower fasting glucose, lower triglycerides, higher HDL, lower systolic blood pressure, lower diastolic blood pressure, lower LDL cholesterol. When we looked at diseases, they had lower risk of metabolic syndrome, lower risk of cardiovascular disease, lower risk of cancer. And when we looked at all cause mortality, for every 10 points roughly in the Food Compass score, they had a 7% lower risk of dying. And so that is a very strong validation that on average across thousands and thousands of products that the Food Compass works well. It has areas for improvement, which we can talk about, but on average, it works pretty well and it predicts better health outcomes.

Dr. Mark Hyman:
Well, I just want to highlight that, because I think what you said is very important, and then we can get into the ways to improve it and the challenges. I think the fact that people are criticizing it ignores the outcome data you just talked about, which is that when you look at what actually happens to people who follow this... And you can kind of reverse engineer who ate what foods through these studies, the large national databases. They lowered all their cardiovascular biomarkers, they lowered their risk of diseases, like you mentioned, heart disease and blood pressure issues and diabetes and death. So while it may not be as good as if you took, like I said, a regeneratively-raised grass-fed this and organic that and only completely unprocessed food, it's a hell of a lot better than what the average Americans are doing. So it's sort of a guidepost to go from terrible to better, to even better.

Dr. Dariush Mozaffarian:
That right. Yeah, that's exactly right.

Dr. Mark Hyman:
So I wanted to also highlight just what you said, which is that many of these scoring systems don't address the problem with refined grains. Our friend David Ludwig says below the neck, you can't tell the difference between a bowl of cornflakes and a bowl bowl of sugar, the refined processed grains, and I think that's an important point that the Food Compass does score for, which is the refined grains and the harmfulness of them. And I think it's really pretty important. So I am really glad that you've done that, and I think that that speaks to the changing science about how we actually need to think about processed starch, which is more or less like sugar.

Dr. Dariush Mozaffarian:
I call it the hidden sugar. Yeah.

Dr. Mark Hyman:
Yeah. So let's kind of dive into some of the controversies in nutrition a little bit more in general, and the-

Dr. Dariush Mozaffarian:
Well, before we do that, Mark, though, I'd love to talk actually about where Food Compass itself, before we talk about controversies, didn't work so well, and where there were some controversies about Food Compass, because there was social media and other things that picked out some products and said why they scored this way. So I think it's good to cover those, if I can. So we scored in our first paper 8,000 products, in our second paper, almost 60,000 product. And again, on average it works really well, but if you look across all the products, especially if you compare across food categories, you see some things that look funny. If you compare within a category, if you compare within breads or within energy bars or within cereals or within meats, it kind of always make sense, but when you start comparing across categories, some things kind of jumped out and were highlighted on social media and led people to question whether Food Compass works well.
And generally the thing that was most noticed was that certain processed foods that are whole grains but were processed and also might have some sugars tended to score kind of in the middle, like a score of 50 or 60, and then minimally processed animal products, certain cheeses and red meats in particular, scored a little bit lower. Still in the eat in moderation range, but scored 40. So why is it that processed whole grain cereals score higher than minimally processed animal foods? And so it's worth unpacking that a little bit. And so first, eggs and poultry-

Dr. Mark Hyman:
Before you explain, I just want to point out that red meat, eggs and poultry all scored higher than the refined grain products like bagels, breads, crackers, cornflakes, and different cereals. So I think people kind of miss that point. I think it's not like all those anal products got scored terrible, and they were variable.

Dr. Dariush Mozaffarian:
Yeah. There was a huge range of how cheeses were scored and eggs were scored and meats were scored depending on what you ate with them, how you cooked it and so on. But I think that's a really important point. Nobody put out a chart showing the thousands of processed cereal products and breads and crackers and energy bars that scored way lower than red meats and eggs and poultry. They pointed out the processed whole grain products that tended to score higher. And some of those whole grain products had no added sugar, some had added sugar. They were mostly whole grain. Whole grain was the first ingredient, but they also had added sugar.
So I think that's a really interesting question which gets to, how do you score minimally processed animal foods, where do those fit, which is one of these controversies in a healthy diet, and how do you score processed whole grains? We know we're supposed to eat more whole grains, but if the whole grain has been finely milled and spit out in the form of a cereal, or... Even whole grain bread in the United States, usually the components of the whole grain have been separated, extracted, and then mixed back together in a factory. It's not like they took a whole grain and milled it, and whole grain.

Dr. Mark Hyman:
So German rye bread, you have to cut with a meat grinder, those deli meat slicers.

Dr. Dariush Mozaffarian:
Yeah. So I think those are valid-

Dr. Mark Hyman:
And break your knife.

Dr. Dariush Mozaffarian:
I think those are valid interesting questions, is does Food Compass score whole grains that are processed a little too highly? They're still better than refined grains, but should they be maybe scored a little bit lower, and should minimally processed eggs and red meat in particular... Poultry and seafood and dairy foods generally score quite well. Should those foods score a little bit better? And so we're looking at that question and looking at scientifically does some of the scoring make sense, and I think we've, over the last year, since science takes time, we've been working on this, and I think we've actually come up with some really good solutions, and we're validating it now to make sure, as we discussed, if you look at Americans and health outcomes, does this system work better than the original system?
So I think our next system is going to work even better, but I think it is an interesting open question, which we can talk about now, is for sure a processed whole grain cereal, even with sugar, is better than a totally refined grain cereal. And for sure a minimally processed whole grain that hasn't been processed at all, or minimally processed like steel cut oats is better than a processed whole grain cereal. We all agree. But is a processed whole grain cereal healthy, or is it not healthy because it's processed? So it's whole grain and it's processed. What wins that battle of healthiness?

Dr. Mark Hyman:
It depends. It depends on what else is in it, how many additives, how many colors, how much extra sugar, what kinds of sugar. There's so many variables. You can take... I've seen a food company do that, like whole grain Cocoa Puffs or something, and I'm like, well, I don't know if that's a good idea. And I think the real question is, what is an ultra-processed food? What is a processed food? What is a minimally-processed food? I don't think people make the distinction. And I've even talked to food industry experts that go, "Oh, you say ultra-processed food, but what is that? And maybe it's not this, maybe it's not that." So could you talk about the definition of what that is, and how you distinguish from an ultra-processed versus a minimally-processed food?

Dr. Dariush Mozaffarian:
Yeah. So there's no single widely, totally accepted definition, but the most widely accepted and used definition comes from Carlos Monteiro, a good friend and colleague in Brazil. His group, it's called the NOVA Classification, and we actually worked with him. We shared a doctoral student who came and visited me in Boston, and we worked together on some of the earlier papers he did, and I even gave a little bit of feedback to the system, which I think might've tweaked it and made it even a little bit better in its early stages. So I like the NOVA system for classifying foods, and it basically classified foods from NOVA one to NOVA four.
NOVA one is basically unprocessed foods, fresh fruits, fresh vegetables, fresh nuts and seeds, things like that, eggs, chicken, unprocessed foods. NOVA two is culinary ingredients. So oils, flowers, sugar, things that you might cook with if you're actually cooking at home, baking at home. NOVA three is processed foods which have a little bit of processing like canned tuna or cheese are considered processed foods. Cheese has the salts for preservation, and canned tuna has the salt in it. And then ultra-processed foods are foods that are made by industry, have multiple ingredients beyond maybe just a little bit of salt for preservation.

Dr. Mark Hyman:
Yeah. Like canned tomatoes or whatever.

Dr. Dariush Mozaffarian:
Yeah. Well, canned tomatoes would be NOVA three, would be processed, and it would be-

Dr. Mark Hyman:
That's what I mean. It's processed, but you still know what it is.

Dr. Dariush Mozaffarian:
And so what Carlos has shown in his research and we've shown in our research too, is on average, if you eat more ultra-processed foods, you have a really bad diet, you have worse health outcomes, and if you eat less ultra-processed foods, you have a better diet, healthier diet, and you have better health outcomes. And interestingly, processed foods, that NOVA three category look a lot more like minimally-processed foods than ultra-processed foods. And so having a little bit of processing seems to be fine. So again, canned vegetables, canned tomatoes, canned seafood seems to be pretty healthy actually. It's really these ultra-

Dr. Mark Hyman:
The sauerkraut pickles, those are processed foods, right?

Dr. Dariush Mozaffarian:
Yeah. So the remaining question though is, okay, now that we know this, what does it mean? Because ultra-processed foods are more than half of the calories in the United States, and [inaudible 00:47:54]-

Dr. Mark Hyman:
Yeah, 60%. It's 67% of kids diets.

Dr. Dariush Mozaffarian:
And we've published some of those papers. And so if you go to the grocery store also, there's a big difference in the helpfulness of ultra-processed foods in my book. If you get a totally 100% whole grain cereal with very few additives that's ultra-processed versus a super refined starch, refined grain, sugary cereal, the whole grain one is better for sure, or energy bars, this is... Me and airports, I travel. You can get an energy bar that's mostly unprocessed nuts with a little bit of honey and added sugar, or you can get an energy bar that's all refined grains. There's a big difference. Or a frozen dinner or a pizza, you could go on and on down the list. So I think that the NOVA Classification is great, and it is what we used as one component of Food Compass, but by itself, we still have to help consumers choose between ultra-processed foods.
There's going to be a gradient within ultra-processed foods. And I think that's a key question. And I think the second question then, just the scientific question to ask, Mark, is okay, we know we need to have some processing of food to have them be shelf-stable and cheap and shipped around the world and convenient, what is it about the ultra-processing that's harmful, and how do we fix it? How do we fix it so that we can have processed foods that are actually better for us? And we can talk about that if we have time.

Dr. Mark Hyman:
I'm even confused, Dari, about what an ultra-processed food is. If you take a whole grain and you pulverize it so it's flour, and then you reconstitute it and add a bunch of vitamins and sugar, is that an ultra-processed food, or is that a minimally processed-food? It's a whole grain food-

Dr. Dariush Mozaffarian:
Well, what's interesting about NOVA Classification, if you do it at home, it's minimally processed, but if a baker does the exact same thing in the bakery and puts it in a package, it's ultra-processed. So even who makes it changes the definition according to the NOVA Classification. So that is interesting, right? That is interesting-

Dr. Mark Hyman:
So by that definition, breakfast cereals, are those ultra-processed food?

Dr. Dariush Mozaffarian:
I think pretty much all breakfast cereals would be ultra-processed, with the exception of let's say if you buy a Bob's Red Mill. I think we have it in our pantry. Bob's Red Mill steel cut oats that you cook. But pretty much anything in a box, in a package that's got the wrap, that's almost all going to be ultra-processed. And of course there's big range of-

Dr. Mark Hyman:
I grew on cream of wheat. I grew up on cream of wheat. I love that stuff.

Dr. Dariush Mozaffarian:
Yeah. The little in instant oatmeal packet that you shake and you put in the microwave, even if it's plain, it has some preservatives, it has a little bit of salt. That's ultra-processed by the definition. But is that the worst thing you could eat? It's probably not perfect, but it's probably better than some other choices. So I think the processing classification is good, but we have to figure out what's harmful. And I know you and I have talked about this personally, but I can just quickly summarize what I think is where the science is taking us to fixing processing. I think that there's basically a couple of things that processing does that makes the food particularly harmful, and a couple things that processing does that takes out things that are good, and that combination is what causes the harm.
So I think what ultra processing often takes out is fiber. Fiber is prebiotics for our gut bacteria. And all of the hundreds of thousands of phenolics and flavanols and bioactives and other nutrients that you were talking about, which I think those two things, fiber and phenolics are two of the most important things in the food supply for health. And so ultra processing takes-

Dr. Mark Hyman:
I think that is so important. When you just said we should... Stop there. Stop there for a sec, because that's a very important statement, that the amount of fiber which comes from beans, grains, vegetables, fruits, nuts and seeds, that's hugely important for our microbiome, which determines everything about our health. And secondly, the 25,000, or who knows how many phytochemicals that are-

Dr. Dariush Mozaffarian:
1.5 million. 1.5 million now that have been measured, by-

Dr. Mark Hyman:
Oh geez, I'm off now. I'm off-

Dr. Dariush Mozaffarian:
... A company in San Francisco. Yeah. A company in San Francisco-

Dr. Mark Hyman:
[inaudible 00:52:14] Oh, I'm screwed up with my numbers then. Last I looked, it at was 25,000. Okay, a million, maybe it's going to be 10 million, who knows, but there's shit we haven't even discovered yet, and these compounds are the medicines in food that regulate so much of our biochemistry, our gene expression, our longevity, our brain chemistry. It's really quite remarkable how these things work. I'm going to send you my book on Young Forever, but I was just shocked to learn about how many of these phytochemicals regulate so many of these longevity pathways and nutrient sensing systems and so many different things that are so critical for our health. So you're right, taking those out are so important.

Dr. Dariush Mozaffarian:
It's what's in cocoa, it's what's in green tea, it's what's in coffee beans, it's what's in nuts and seeds. It's these hundreds of thousands of compounds. So I think ultra processors generally take those out, and and then they add things. So they add added sugar and salt, and for sure we know that's bad, but I think beyond added sugar and salt, and beyond phenolics and fiber missing, people have thought about those four things, I think the fifth and maybe most central harm is what I call acellular nutrition and what others have called acellular nutrition.
The intact food structure has been totally destroyed. And so-

Dr. Mark Hyman:
Yeah. Pulverized. Right.

Dr. Dariush Mozaffarian:
... Any food we plant, or an animal has some intact cellular structure, and when we eat that, the intact cellular structure changes how quickly and where in our digestive system the food is digested. And so if you eat steel cut oats, for example, steel cut oats have some intact food structure, it gets slowly digested all the way through the GI tract so that by the time it even gets to your large gut, there's still some intact starch and sugar and food in there, and your gut bacteria digests that. They're healthy, they're happy, they're like, wow, we got steel cut oats for breakfast.
But if you have a finely milled, highly processed whole grain, it has the fiber, it might even have some of the phenolics, but it's digested very rapidly because it's acellular, the cellular structure's been destroyed. And so I think acellular carbs in particular are negative, and I think acellular proteins are negative. We can talk about this, Mark, but if you have protein and you're not working out in the gym building muscle, if you have protein and amino acids get into your bloodstream from eating processed protein or the extra cup of protein powder in your shake or protein bar, or these plant-based meat alternatives that have ultra-processed protein in them, if you're not pumping iron, that gets turned into fat by your liver. That all goes to fat.
And so it causes insulin resistance. There's been trials showing that high protein diets, if you're not exercising, cause insulin resistance. So I think acellular carbs for sure, and maybe acellular proteins are some of the worst things in the food supply. And so what all that means is, if food companies can invest in and understand how to make all the processed foods that we like to eat, but keep the fiber, keep the phenolics, don't add as much sugar and salt, and keep the food structure more intact, we'd have a healthier food system.

Dr. Mark Hyman:
Yeah, I think you're right. And I think one of the things I want to unpack here is, and I think is some of the reason for the pushback, is that some ultra-processes were scored high in Food Compass, and I think we talked about this, but one of the challenges is, the things that for me was missing, but it was sort of approximated with the carbohydrate fiber ratio, was the impact of different foods on insulin secretion, glucose, which to me is one of the biggest drivers of chronic disease and aging in this country. So absent that in the thing, you get high scores for orange juice, which I wouldn't highly recommend, or some of these processed cereals, which may be whole grain, and they get a good score for that, and they don't have a ton of sugar, but is that really a good idea?
So what's the glycemic load of some of these cereals when you take them alone, or even if you have them with milk? So I just have this in my head that people are pushing back because there wasn't an ability to use this framework of how these foods impact blood sugar directly or insulin. Can you speak to that?

Dr. Dariush Mozaffarian:
Yeah. Well, so first, the vast majority of feedback we've gotten on Food Compass has been very, very positive. And so we've had researchers from other countries around the world actually contact us, say, "We see these other food rating systems, Food Compass is much, much better. Can you work with us to create a Food Compass for our nation?" We've had people working in healthcare centers and healthcare clinics working with low income populations who say, "We want to give a simple guide to our patients to help them eat better. We really like Food Compass." We've had non-profit organizations, app developers, employer wellness companies, lots of people who actually read the papers in detail and say, this is great and we'd like to use it. So I don't want to overemphasize that there's been pushback. Where the pushback has been is if you just take 10 or 20 of the products-

Dr. Mark Hyman:
Well, I was just raising some of my concerns as I read it, even just my thinking about it.

Dr. Dariush Mozaffarian:
Valid. Very valid. So I think the questions you're raising are very good, open scientific questions that I think we should have some real honest scientific debate about. The number one source of whole grains in the United States is breakfast cereals. That's the top source where Americans are getting their whole grains. And many food companies have actually done that through stealth. They haven't said it, they haven't told us. They've changed all these processed zero products to be almost entirely wholegrain, sometimes [inaudible 00:57:53]-

Dr. Mark Hyman:
And they put on it on the front of the package. They're not shy about advertising it.

Dr. Dariush Mozaffarian:
They're not advertised as wholegrain cereals, some of them, because they have sugar and other things in them. Most Americans don't know, I'll put it that way, that they have whole grains in them. So I think that's an open question, is what is the impact of that on health? And I think the way I look at it is, they're definitely better than the original refined grain version. So that's an improvement. They're definitely worse than a minimally processed whole grain that you might, again, get steel cut oats and cook it overnight and eat it in the morning, but I think it's an open question is how healthy are they by themselves? And you and I kind of looked at this over the last week and shared some studies back and forth. Overall, randomized trials in people show that if you give people more whole grains in place of refined grains, you lower insulin, you lower hemoglobin A1C, you lower glucose, you lower triglycerides, and so you improve metabolic health.
Most of those trials use minimally processed whole grains. So it doesn't answer this particular question. There have been two trials which we kind of looked at together. They're not great, but there have been two trials, one funded by Food Industry, that have looked at processed whole grains... Kind of have a refined wholegrain, they've looked at processed wholegrain... Just to be clear for listeners, a refined grain is you've taken out the bran, you've taken out the germ, and all that's left is the starch. That's a refined grain. So a refined grain is starch.

Dr. Mark Hyman:
Yeah. There's no oil, there's no fiber, there's no mineral, there's no vitamins.

Dr. Dariush Mozaffarian:
It's just starch. And starch is glucose. Starch is 100% glucose. So corn starch, rice starch, wheat flour, multigrain, it's refined grain. So a wholegrain is, you have the bran, the germ, the endosperm, but it might be finely milled and processed. So I should say... Let me just go back, processed whole grains. So there have having these two trials with processed whole grains, and both of them in patients with diabetes also actually showed some benefit compared to refined grains. So that's one piece of evidence. And then secondly, we have observational studies. We have multiple long-term observational studies, which have their limitations, but in those long-term observational studies, the majority of the wholegrain consumed is processed wholegrain. It's processed wheat bread, processed crackers, processed pasta, processed cereals. And in observational studies, people who eat more processed whole grains have lower obesity, lower risk of diabetes, lower risk of heart attacks, low risk of stroke, low risk of certain cancers. So if you take the limited trials we have, not much, and the long-term observational studies we have, my gut sense, no pun intended, is that compared to the current pretty bad American diet-

Dr. Mark Hyman:
Microbiome intuition.

Dr. Dariush Mozaffarian:
Yeah. My microbiome intuition. Compared to the pretty bad American diet, processed whole grains are a good choice today. Compared to the ideal diet, they're probably not a good choice, but compared to the current American diet, I think they're a good choice today.

Dr. Mark Hyman:
Yeah, I agree. I think it's always like my sister telling me this joke, the Vermont farmer gets asked, how's your wife? And he goes, compared to what? And I think what are we comparing it to? And I think if compared to the traditional standard American diet, the sad diet, clearly adding whole grains in any form is an improvement, but it's really about the total complex mixture of your diet. And that's why parsing these individual ingredients is problematic. When you include 54, it gets a lot better than just doing three or four. And so that's really the attempt, to try to keep improving. And I think you're going to learn a lot more. I think there needs to be some tweaks in it.
One of the things I noticed was that cholesterol was used in there as a metric. I don't know if that was a ding or a negative or a positive, but I think it was a ding on the score. And I wondered why that was included, because the new dietary guidelines recommendations are that it's not a nutrient concern, and that it doesn't really dramatically impact blood lipids, even though it sounds like cholesterol in your blood, cholesterol in your food. It's confusing. So can you just talk about that?

Dr. Dariush Mozaffarian:
Sure. Yeah. So we have one domain called trace lipids. And so in that domain, we want to include trace fatty acids, trace fats, trace lipids, that at small amounts have important biologic effects. And so there we have seafood-based omega-3s like EPA and DHA, we have plant-based omega-3s like ALA, we have industrially-produced trans fatty acids, which aren't that common in the United States anymore, but are present in other countries. I think we wanted to... I'll have to go back and look now. I think we have branch chain fatty acids was a concept. I don't know if we were able to get measurements on that. That was a concept to put in there. Medium chain triglycerides was another concept we thought about putting in there.
But we didn't decide to include cholesterol in there, and the reasons for that is reviewing all the science, the 2015 dietary guidelines said cholesterol is no longer a nutrient of concern for over-consumption in the United States, because the average cholesterol consumption in the United States is about 200 milligrams per day, the recommended maximum is 300. Very few Americans are consuming over 300, so they said it's no longer a nutrient of concern. That doesn't mean it's not biologically relevant and it doesn't do anything. And I've reviewed all the evidence. Up to 300 milligrams a day, cholesterol probably doesn't have a big impact. Over 300 milligrams per day, 400, 500 milligrams per day, which again is not common in our country, but in other countries still we sometimes see, it does start to raise bad cholesterol, it is associated with harm.
And interestingly, dietary cholesterol at current levels in the United States is associated with diabetes, not heart disease, diabetes, observationally. People who eat more cholesterol are at high risk of diabetes. I don't know why. It's observational. It may be confounded. So we decided with that kind of mixed evidence, we should include cholesterol, but it's one component of five in one domain. And so if a product like eggs, for example, have a high cholesterol, at most it might reduce its Food Compass score by a point or two. It's not going to reduce the points by five or 10 points. And I think a boiled egg... I can't remember in our paper, but I think a boiled egg gets a score of 55 or 60, food eaten in moderation, kind of a upper end of a food eaten in moderation. Even with cholesterol, it doesn't get a bad score. So I think that's a valid question-

Dr. Mark Hyman:
Although it gets a worse score than egg whites, right? It gets a worse score than egg whites, right? If I had to choose, I would choose-

Dr. Dariush Mozaffarian:
I think it gets a worse than egg whites probably because of the fat ratio more than the cholesterol. The cholesterol probably has a tiny, tiny [inaudible 01:05:04]. But I think it's a fair question. You could say, would... And that was the consensus of the scientific team that put it together. But we could have created it without cholesterol, and I think it probably would've worked almost exactly the same.

Dr. Mark Hyman:
Yeah. Yeah. Fair enough. I think for everybody listening, there's a lot here to dive into, and we literally are scratching the surface. And I think Dari and I could talk for days and weeks about all these topics and the fine points of nutrition, from sugars and processed foods to oils, to meat and all the data on it. And maybe we'll have him back for another podcast. I think doing what you do is not easy, trying to go through the mountains of data, and sometimes it's junk in, junk out, sometimes there's better studies. It's hard to make sense of, and I think you are one of the, I think in my opinion, one of the most prolific and also most thoughtful and balanced scientists out there in the field of nutrition. So I thank you for your tireless work and your constant good humor. I don't know how you do it, but you do. And we'll get more into these topics later, because I think we have a lot more to unpack as we go forward in this world of nutrition and how to make the world a healthier place.

Dr. Dariush Mozaffarian:
I appreciate the conversation, and thanks for all of the work you've been doing to promote better understanding of nutrition. And I will say, Mark, that we absolutely need to radically reinvent the food system. The food system is broken, it's making us sick, it's causing health inequity, it's crushing our healthcare system and our economy, so we have to radically reinvent the food system. And we can do it. We can actually do it. We can do it with the technology and figuring it out on science. We need some investments to figure it out, but we can do it. And while we're doing it, we need to help people eat better with what we have today.
So it's not a either or. We have to do it all. We're not happy with the current food system, but we have to help people make better choices and navigate within it, and we have to radically reinvent the food system at the same time. And we've published policy papers on this. Hopefully we can link to it in your podcast, some of our taskforce report for the White House Conference [inaudible 01:07:15]-

Dr. Mark Hyman:
Absolutely.

Dr. Dariush Mozaffarian:
There's a whole bunch of things that are very doable, very sensible that we can do to fix the food system. So look forward to getting there and to feeling young and healthier longer for all of us.

Dr. Mark Hyman:
Absolutely. And it just reminds me of that saying, don't let the perfect be the enemy of the good. I think we're not perfect, but we're getting better. So thank you Dari for your work, and I look forward to working with you more in D.C. If you love this podcast, please share with your friends and family on social media, leave a comment, what have you learned, what do you think is good and not good, how have you found these ideas helpful for you, and subscribe wherever you get your podcast, and we'll see you next week on the Doctor's Pharmacy.
Closing:
Hi everyone. I hope you enjoyed this week's episode. Just a reminder that this podcast is for educational purposes only. This podcast is not a substitute for professional care by a doctor or a other qualified medical professional. This podcast is provided on the understanding that it does not constitute medical or other professional advice or services. If you're looking for help on your journey, seek out a qualified medical practitioner. If you're looking for a functional medicine practitioner, you can visit ifm.org and search their find a practitioner database. It's important that you have someone in your corner who's trained, who's a licensed healthcare practitioner and can help you make changes, especially when it comes to your health.