For nutrition and health professionals, who get a great deal of their funding from food companies, it's just as easy to say, "Well, all foods can fit into a healthful diet. I mean, eating sugar isn't bad for you." And it's not, in small quantities. But they don't really put it in its quantitative context. At this point, with obesity being such a problem in the United States and throughout the world, calories are the single most important issue to focus on, and we need to talk about calories. Nobody wants to talk about calories, because the minute you talk about calories, you have to talk about eating less, and the minute you talk about eating less, you're doing something that's bad for business.
Talk about the public health stakes. What illnesses can we prevent or ameliorate?
Well, we know what diet-related illnesses are. They're the dietary factors that raise blood cholesterol, raise blood pressure, and raise blood sugar levels, and lead to conditions such as obesity, heart disease, stroke, cancer. These are leading causes of death and disability in the United States.
If we just look at obesity alone, and the costs of overweight to the society as a whole, the estimated figure that's being thrown around is $117 billion a year. Whether it's right or not doesn't really matter. It's going to be a huge number, because the cost of type 2 diabetes alone is simply staggering to contemplate. And the idea that we're seeing type 2 diabetes in young children, where it was never seen before, or so rarely seen before that people wrote about it in the medical literature--
It used to be adult onset.
It used to be called adult-onset diabetes. And now it's childhood-onset diabetes. The cost of that terrible disease is simply impossible to contemplate. So we're not just talking about a cosmetic problem here. We're talking about healthcare costs that are being superimposed on a healthcare system that's already in very serious trouble. And it's not just here. It's everywhere in the world.
Beginning of the 20th century, the concern was that people ate enough, not about obesity.
No. If you look at the history of nutrition in this country, the United States has always produced enough food for its people. That's never been the problem. Its distribution may have been a problem. But even at the early years of this century, the most serious diet-related diseases were diseases due to under-nutrition, not having enough of the right foods, or enough variety of foods, or enough calories. That situation didn't really change until after the Second World War, when food distribution was improved and the economy improved, and people started eating more. At that point, heart disease rates started increasing and we began seeing the American Heart Association talking about what kinds of dietary changes needed to be made in order to lower heart disease risk. And they've been very successful in promoting some of those changes.
From the 50's onwards: Eat a balanced diet but eat less saturated fat.
Yeah. The early dietary advice was to try to encourage people to eat more of American agricultural products, eat a variety of foods in various groups. When the Department of Agriculture first started issuing dietary advice in the early years of this century, the advice was to choose foods from a variety of food groups. That was very uncontroversial advice. Everybody should be encouraged to eat a varied diet.
But when the situation changed and we began looking at problems related to over-consumption of foods or specific components of foods in the diet, that's when things got controversial. The American Heart Association realized early on that saturated fat was something that raised blood cholesterol levels, and blood cholesterol levels were a risk factor for heart disease -- advice, by the way, and knowledge that has not changed in the intervening years. Then the advice was to eat less of the sources of saturated fat. And then you were in political trouble, because the main sources of saturated fat in American diets are meat and dairy products, and meat and dairy products have huge lobbies that don't like the American government or heart association or any health agency telling the American public that American animal food commodities are bad for health.
Despite that lobbying, there was a shift towards using vegetable oils as opposed to animal fats.
Yes. There was a huge educational campaign to try to get people to eat less saturated fat, and that encouraged Americans to choose low-fat milk over whole milk -- that's been a big shift -- and to use vegetable oils instead of animal fats.
But what didn't accompany that message was a calorie message. Somehow calories got lost in all of that, and the individual nutrients or the individual components were taken out of their caloric context. So when fat was removed from foods, calories came in from sugars, and that didn't help the calorie situation very much.
Talk about the [changes that have been made] over that period.
… The good changes are that low-fat milk replaced whole milk. That was a good change. Vegetable oils replaced animal fats. That was a good change.
But there've been other changes that are more alarming or more disturbing in several ways. I mean, one is the replacement of milk by soft drinks and juice drinks. A tremendous lobbying effort has gone into that, and the companies that make these products have tried to encourage Americans and have been very successful in doing that, to convince Americans that soft drinks are okay to drink all day long, and that they're really okay for kids to drink all day long. That's been a big shift, and one that I think has a great deal to do with over-consumption of calories.
Other shifts have been a decrease in use of beet and cane sugars, sucrose, and its replacement by corn sweeteners. And there, the problem is that corn sweeteners are so much cheaper than sucrose, for reasons having to do with federal sugar policies. And the cheap corn sweeteners go into lots and lots and lots of food products, lowering their cost and encouraging people to buy them, because the low cost of food is an incentive to buy more of it.
You don't think this low-fat message backfired on nutritional advisors?
Well, in the late 1980s, there were two major reports that came out, identifying dietary fat as the single most important change that needed to be made in order to improve diet and health. And the reasons for that message were that some of the fat was saturated. The idea was to reduce saturated fat, but the assumption was that it was too complicated to explain all that, and that if people just reduced their fat content, the fat content of their diet, they would be improving it.
What nobody realized -- or at least I certainly could never have guessed -- was that the food industry would substitute vegetable fats for animal fats in such a profound way, and would also substitute sugars for fats, and keep the calorie content of the products exactly the same. The best example is the Snackwell phenomenon. Snackwell cookies were advertised as no-fat cookies, but they had almost the same number of calories. And in fact if you go to the store today and look at Oreo cookies, they have a reduced-fat Oreo cookie that has, I think, six calories less than the regular Oreo cookie. It's lower in fat but it's higher in carbohydrates.
Did consumers see "low fat" and miss the idea that you could get fat with other things besides fat?
Yes. I think that the "low-fat" message was interpreted as, if you had a product that was low in fat, it was good for you, without thinking of calories. Remember, nobody wants to talk about calories. Nobody wants to. The minute you start talking about fat in its caloric context, then the issue of adding sweeteners back to these low-fat products becomes very obvious. It's the same thing now with the low-carb products. They still have calories. Just because it's low-carb doesn't mean it's healthy. Just because it's low-fat doesn't mean it's healthy. It's still going to have calories, and calories are what counts.
The switch from animal fats to vegetable fats: Baking needs solid fats?
The hydrogenated fats have been with us for a long time. And we've known since the 1970s that hydrogenated fats have these trans fats in them that have roughly the same effect as saturated fat, so in effect, convert some of the unsaturated fats into saturated fats that are clearly not particularly healthy. So that's another factor.
It's taken advocacy organizations years and years of very hard work to get the Food and Drug Administration to finally agree to label trans fats, and I think that as soon as that label actually goes on the packages, we'll see the trans fats out of the food supply.
That's due for 2006?
2005 or '6. I can't remember when it is. But the companies are already starting to get them out, and you can go to the supermarket and look at food products and see lots and lots of food products advertising "no trans fats." In fact, the PepsiCo Company in its Frito Lay line, has had full page ads in The New York Times advertising these snack foods as if they were health foods: zero trans fats. Well, they've still got calories.
When it's inevitable and it's labeled, they will then try and use it as a marketing advantage.
Yes. The food industry is in trouble, in the sense that it is in a hugely competitive environment. Our country has available in the food supply 3,900 calories a day for every man, woman, and child in the country. That's roughly twice the actual population need. Food companies are beholden to stockholders. They have to grow in order to maintain their stock prices. We already have 3,900 calories a day and 320,000 different food products in the American marketplace. They can't all keep growing in that situation. So all they can do is to try to get consumers to eat their products instead of somebody else's, or to eat more in general, and they're just terrific at doing that.
And they do that not only through advertising and marketing, but also by enormous efforts to change the social environment, so that it is now socially acceptable for children to drink soft drinks in school and all day long, for babies to have soft drinks in baby bottles, and for people to snack all day long and to eat food in larger and larger portions, all of which are strategies to encourage people to eat more.
You were an adviser to a surgeon general's report?
I was the managing editor of the 1988 Surgeon General's Report on Nutrition in Health, which was one of those reports that came out identifying dietary fat reduction as a major public health priority.
When you were doing that, you were struggling with the complexity of nutrition?
We were struggling not only with the complexity of nutritional advice but also with lobbying activities from food companies, that made it impossible for the surgeon general's recommendations to say eat less of anything. So if you look at those recommendations, those recommendations are: Choose lean meat. The report couldn't say: Eat less meat. Eat a diet moderate in sugar. The report could not say: Consume fewer soft drinks. This was, after all, the Reagan administration. It was very pro-business, and it really wasn't possible to put in any "eat less" messages. That is still true. If you look on the Web sites of the major federal organizations and agencies that are dealing with the obesity epidemic, not a single one of the says, "Eat less." They all talk about activity. Now, mind you, activity's very important and I'm for it. But I think we have to talk about diet as well.
Did you think the 1992 food pyramid might make a difference? Were you then surprised that the obesity epidemic has grown through the decade since?
Remember, that 3,900-calorie-a-day figure is 600 calories higher than it was in 1970. A hundred of those calories came just between 2001 and 2002. So the food supply is expanding, putting increasing pressure on food companies to sell more in a competitive environment. That happened along with the pyramid advice.
The pyramid was meant to be released in 1991. At that point, the meat industry and the dairy industry got wind of it, didn't like where their products appeared, sort of towards the top of the pyramid, and complained so bitterly to the Department of Agriculture that the Department of Agriculture withdrew it, and redid the research and went through a year-long lobbying process that resulted in the 1992 release of the pyramid. It was already incredibly political, right from the outset.
Now, I thought that the advice would indicate that you were supposed to eat fewer meat and dairy products, and that would lower the fat content of the diet. … It never occurred to me, when the pyramid was released, that the sizes of servings of grain products in particular would increase so rapidly during the decade in the 1990s. What happened was that muffins that used to be 1 or 2 ounces expanded to 8 ounces. Soft drinks that used to be 8 ounces expanded to 64 ounces. Pretzels that were 1 ounce expanded to 7 ounces. You eat one of those 7-ounce pretzels and you've done your grain servings for the day. But most people don't realize that.
The low-fat advice makes sense, and presumably you still stand by it?
Yeah. If you're going to lose weight, the easiest place to start is with fat, because it's got twice the calories of either protein or carbohydrate. So it's a great place to begin. The second great place to begin is with soft drinks and those juice drinks, because they add calories and no other nutrients.
Why was the Atkins diet always popular, even against medical/nutrition opinion?
I think the Atkins diet is popular because it waves a magic wand and it says everything that was bad for you is now good for you, as the cartoon in the New Yorker said. And there was a cartoon just like that that showed a fairy godmother waving a magic wand. Everything that was bad for you is now good for you. So people get to eat forbidden foods. Everybody likes that.
There also must be something about the Atkins diet that increases feelings of satiety so people aren't as hungry. What the Atkins diet does is to lower caloric intake. In fact, all diets lower caloric intake. The question is whether it's healthy in the long run and whether it's sustainable. And I think the jury's still out on that one.
When you saw the cover story in The New York Times Magazine, "What If It's All Been a Big Fat Lie," what did you think?
That particular article has absolutely ruined my life as a nutritionist. I can't go anywhere without being asked about it. It attracted so much attention, and was so inflammatory in the way that it was written, that I think it's really caused the nutrition community to stand up and take notice and try to deal with it in a way that seems reasonable to people. Because there's no question that people lose weight on the Atkins diet. They absolutely do, if they follow what the Atkins diet actually says, as opposed to what it seems to say that it's saying. You can't eat everything you want and lose weight on the Atkins diet. You do have to restrict calories. But it seems easier to do it.
What that article did, I think, was to establish the debate as one that needed to be more complicated than just saying, "East less fat." It really required the nutrition community to talk about good fats and bad fats, and good carbohydrates and bad carbohydrates, and to try to educate the public about what those are. But I think all of that is a distraction from calories.
Is the article a good or a bad thing?
I think it's complicated. There's some good things about it and some bad things about it. I like debates, and I think the writer is a very good writer who had a serious message that he was trying to get across, one that he had written in a much more tempered form in Science magazine a year earlier, a much more nuanced and carefully written piece, in my view. This was much more sensationalistic.
It also put forward an alternative hypothesis: Fat is no longer the bad guy. The bad guy is carbohydrates, driving towards a new theory of glycemic index.
Right. I don't see these as new theories. I see these as part of a discussion about what you do when you're overeating calories, because it's very clear that taking in more calories than your body can handle easily deranges metabolism in all kinds of ways. That's where the "good carb, bad carb," "good fat, bad fat" issues become very important, because a very high-carbohydrate diet on top of a diet that already has too many calories is clearly very difficult for the body to handle.
The food industry is now gearing up to produce low-carb products.
Yeah. We're going to now see a huge proliferation of low-carbohydrate products. To the extent that these products help people reduce their calorie intake, I think they'll be fine. Once people find out that if they're still overeating calories, these products aren't going to work, then it's just another fad. But all of it is a distraction from what I see as the most important issue, which is to eat more fruits and vegetables and watch your calories.
A food technologist says there's four basic ingredients in food. If you take one out, you've got to put something else in. We looked at a food which was low fat, zero carbs, 80 percent protein.
And the rest of it, some sort of indigestible fiber.
Can you eat as much of that as you want?
Why would you want to? I mean, to me the issue is just extremely simple. It's: eat less, move more, and eat your fruits and vegetables. It isn't any more complicated than that.
And you know, I ask the question: To whose advantage is it to have the public confused about nutrition? Clearly it's to the advantage of the food industry, the diet industry, the diet product industry, the drug industry because they make diet drugs. The pharmaceutical industry is part of that. The healthcare industry, because overweight people are going to be unhealthy and that's going to keep doctors in business.
It gives journalists better stories, doesn't it?
Right. And journalists like to write about single nutrients because it's easier to write about single nutrients. It's very hard to talk about context. Nobody cares about context. It's complicated. It's messy. And yet in order to understand dietary issues, you need to understand the context.
Who are the healthiest people in the United States? The healthiest people in the United States are the ones who are best educated and have the most money. They choose the best foods, they eat best, they follow a whole range of healthful practices. They don't smoke. They don't drink too much alcohol. They don't take drugs. They lead active, busy, productive lives. These are the healthiest people in our country, and these are the people who need the advice least, because they're already following a whole range of lifestyle practices. One food product isn't going to change the way they live because they're already living well.
It's the large proportion of the American public that may not have enough money to buy healthful foods, that isn't as educated, that doesn't know how to interpret these messages in context, and that doesn't have the means or the time to try to figure out what to do in this confusing marketplace, that leave this huge opening for food companies to market to people who don't know how to handle that kind of marketing. When you hear on television that food companies are marketing to 6-year-olds and think that that's an appropriate thing to do, then you understand what the stakes are in this.
Some nutritionists think it was a mistake to oversimplify, that people should know about good and bad fats, good and bad carbs.
Oh, I would absolutely agree. I mean, I would say that if the Surgeon General's Report on Nutrition and Health made one mistake, it was to oversimplify. The other mistake was a political mistake, which was to not say what the report meant. The report meant: Eat fewer calories. Eat less meat and dairy products. Stop eating soft drinks and junk foods and snack foods. But it couldn't say that for political reasons. Even the slightest hint of an "eat less" message had the lobbyists in the office that was preparing the report, in force, and had the lobbyists talking to the Congress people about this dangerous report that was going to come out, that had these un-American statements about how Americans should eat less meat.
What's more important than all these details and nutrition advice?
Well, the concept is so simple, it's just laughable. It's: eat less, move more, and eat more fruits and vegetables. There is an enormous research basis for all of those. By eating less, it doesn't mean starving yourself. It just means maintaining a caloric balance that balances calories in and calories out. That's all it means. Being more active doesn't mean going to a gym every day for hours and hours. It just means moving your body from point A to point B, and doing it on a regular basis. The fruit and vegetable message is a very clear one with a very strong research basis behind it. Everything else is a distraction, and the worries about what this nutrient or that nutrient [does], or whether it's carbohydrate, fat, or protein, really doesn't matter nearly as much as the calorie issue right now.
Now, it may be that if people were maintaining a better calorie balance, that we would go back to being tremendously concerned about the balance between good fats and bad fats, and good carbohydrates and bad carbohydrates. My own advice to people who want to start maintaining caloric balance is to stop snacking, or to reduce the number of snacks, don't eat very many times during the way, stop drinking soft drinks and juice drinks completely -- that's a terrific place to begin -- and eat foods in smaller portions.
That advice is much easier to follow in theory than it is in practice, because there is so much effort to create an environment that encourages people to eat more, to eat more often, to eat in more different places, at more different times of day, and to provide foods that are so convenient that all people have to do is reach and there are the calories right there. There are wonderful research studies right now that show that people will eat more candy from a bowl that's sitting right in front of them than they will from a bowl that's 10 feet away. It's really that simple.
Characterize the obesity problem as a public health problem. Compared to 20 years ago, is this a worsening problem?
The issue of obesity became prominent just within the last 15 years. This is very recent. It's too recent for a genetic change, and so we have to look at societal changes that have taken place. So what are the main societal changes that have taken place? One, the number of calories in the food supply has gone up. Two, food marketing has increased and become more aggressive. Three, portion sizes have increased. Four, pressure -- it has become more acceptable in society for people to eat more times during the day, and in different locations where food was never seen before.
The result of this is very clear. We're seeing type 2 diabetes, which used to be called "adult-onset diabetes," in very young children. This was never seen before, or hardly ever seen before, and this will be a lifelong problem to manage, and something that will be very expensive to the country, to the people themselves, and to the healthcare system. We're seeing an epidemic of overweight that is occurring so rapidly that the Centers for Disease Control can track it from year to year, and does so on those beautiful maps on its Web site.
Does this now exceed smoking as a public health issue?
My understanding is that the problem of overweight is equivalent to the problem of smoking.
What will be the main drivers for us to change?
Well, I think we're already seeing a major society shift. We're seeing a backlash. We're seeing schools looking at the marketing practices in the schools and throwing them out. We're hearing more and more talk about regulation of advertising on children's television. We're hearing talk about tax strategies, legal strategies, elimination of farm subsidies. The lawsuits have gotten everyone's attention. But I think probably the biggest driver comes from the investment analyses that have come out, looking at the vulnerability of food companies to loss of sales if they don't change their market practices and their product mix.
How would they lose sales?
The investment analyses -- and there have now been three of them that I'm aware of: one from UBS Warburg, and J.P. Morgan in Great Britain, and another from Morgan Stanley in the United States -- all three of them say the same thing, that if people start losing weight, they're going to have to be eating less. Eating less is going to be bad for business, and it's going to be much worse for some businesses than others, so that if these food companies don't fix their product mixes to make healthier food products, and market them in a way that emphasizes the healthfulness of food products, especially those that are lower in calories, they're going to be left behind in this mass movement towards more healthful eating.
But eating less: If the average American eats 1,600 pounds [of food] a year, and they're competing for a share of this stomach, what can they do?
I don't have a very happy message for the food industry. I think they've been given a free ride in marketing for a long time now, and that free ride is now over and it should be over, particularly the marketing to children, which I think crosses an ethical line. They can't all grow in a competitive marketplace. They have argued for years that this is a matter of consumer choice. Well, consumer choice is going to come back and bite them, and that's just how the system works. If they're going to be participants in the system and they're in an over-inflated, over-abundant food marketplace in which there is far too much food for anybody to eat healthfully, some companies are going to lose and some companies are going to win. The winners are going to be the ones that can take advantage of the trends towards more healthful eating, and the losers are going to be the ones that are still marketing junk food.
But what drives us as consumers to eat less?
I'd like to see an education campaign that really tells the truth about diet and health. We never had one. Let's have one that's free of political influence, and says "eat less" when it means "eat less." That would be worth trying.
As consumers, we have our own health to worry about. We make individual choices. People need to be aware, for example, that larger portions have more calories. That may seem obvious, but it is not.
So just like people became smart about not smoking, we can solve this problem through education?
I think education is a big part of it. I think changing the environment is a big part of it. I'd like to see us try to find ways to change the environment to make it easier for people to eat more healthfully, in the same way as the environment had to change before people would stop smoking. …
Looking ahead 20-25 years, will we have confronted this obesity epidemic?
I'm always optimistic. I see so much change taking place in the society right now, and so much public awareness of what a serious problem this is and why we need to do something about it, that I can't help but be optimistic.