Food for thoughtBMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2463 (Published 13 June 2018) Cite this as: BMJ 2018;361:k2463
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We should eat freshly cooked meals
Congratulations to the BMJ for publishing this series of papers on food and nutrition science and policy (1, 2), and thus maintaining its proud record of upholding public health. Congratulations too to BMJ editor-in-chief Fiona Godlee for stating that ‘The BMJ is a campaigning journal’ (3). Congratulations also to all those who have created 12 important papers with 46 authors and nearly 1,000 references.
The BMJ series states in its introductory editorial: ‘More articles are planned in the coming months’. This is good to know. The rest of this letter suggests some approaches for more papers. Our suggestions are guided by some general concerns. Here are two.
First. More than 90% of authors of the present series of articles are affiliated with academic centres in high-income countries, and of the leading authors of the scientific papers, all but one are from US or UK universities.
This is not just an issue of geographical balance. Many high-income countries, certainly including the US and UK, have food systems where indigenous, traditional or well- established dietary patterns based on fresh or minimally processed foods and freshly prepared meals have been largely displaced notably since the 1980s by all sorts of packaged snacks, carbonated soft drinks (soda), sweetened ‘fruit’ and ‘milk’ drinks, ‘cereal’ bars, pre-prepared pizza, ‘chicken’ ‘nuggets’, and many other types of ready-to-consume, ultra-processed food and drink products (4-8). This greatly concerns scholars and policy-makers within countries at all stages of economic development.
By contrast, many low- and middle-income countries, although bombarded by the ultra-processed food manufacturing industry, with sales of various of their products increasing by 2-10% a year (9), still maintain traditional food systems. Large sections of the population in these countries (10-12), as well as in some high-income countries such as France (5, 13), Italy (5), and South Korea (14), still acquire foods for preparation and cooking in the form of regular fresh meals as a central part of living well.
Surely, the nature and solutions of problems that have to be faced in these contrasting food systems are different. The BMJ editorial rightly says that ‘food is central to culture and identity’. Scholars from countries where diets are based on freshly prepared regular meals, often enjoyed in company, are naturally liable to see problems and solutions differently from scholars in countries dominated by ultra-processed products, confronted by the omnipresence of thousands of types of packaged products typically snacked or drunk alone. Thus in some countries an increase in sales of reformulated ‘diet’ sodas could be seen as a public health success, whereas in other countries it could represent further displacement of fresh foods and regular meals. Likewise, promotion of cooking skills among children and young adults might seem utopian in some countries, but is a natural and feasible priority in others.
In this respect, awareness of cooking and of regularly consumed meals in this BMJ series is low. Neither is much mentioned in any article. Neither is discussed, and some mentions are merely within tabular lists. There is s rightly extensive discussion of breastfeeding, but nothing on regular meals as the natural basis of everyday dietary patterns for populations throughout the rest of life.
Second, and related to the first concern, the terms ‘processing’ and ‘industry’ are generally used loosely in the series. Almost all food is processed in some way. Grains are dried and packaged or transformed into flours and pasta, milk is pasteurized, fresh meat is chilled or frozen, and so on. No population guidelines recommend consuming only fresh food, and consumers should never be given the impression that all processed food is unhealthy. Minimal processes such as drying, grinding, pasteurization, chilling, freezing, fermentation, and packaging are often necessary or beneficial.
What requires focus here is specific types and forms of food processing, particularly those where complex evolved food matrices are destroyed and replaced by formulations of cheap, long-duration ingredients, such as processed starches, sugars, hydrogenated fats, protein isolates, and synthetic micronutrients, with additives other than preservatives used to make the final product palatable, or hyper-palatable (15). What also requires focus are the transnational corporations that manufacture, distribute and sell ultra-processed products, whose businesses have grown exponentially since the 1980s, and whose often colossal sales and profits come from intrinsically unhealthy products that cannot be made healthy by reformulation (9, 16, 17). We have failed to find the term ‘transnational corporations’ in any of the BMJ series of papers.
We suggest that the BMJ follows this series on the science and politics of nutrition with a further co-ordinated series of papers involving more authors from regions and countries whose food systems expressed as freshly prepared regular meals still survive. Nutrition scientists should be joined in this work by scholars from other relevant disciplines, such as anthropologists, ecologists and economists.
These new papers could bear the following key words and phrases in mind, depending on the topic of papers:
Chronic non-communicable diseases, Malnutrition (all forms).
Dietary patterns: food- and meal-based, versus ultra-processed food based.
National dietary guidelines.
Quality of life, Well-being, Wellness
Meals, Cooking, Culture, Food processing.
Primary producers, Rural economies, Transnational corporations.
Globalisation, Equity, Human rights, Justice.
Food crises. Food prices. Food support.
Natural and physical resources, Environmental degradation, Quality of air, soil, water.
The industrialised food systems of the US and UK have developed in a way that is not a global model. Nutrition scholars, clinicians and concerned citizens are increasingly aware that these are an important cause of crises that affect well-being, health and disease now and as projected more in future for future generations, including corrosion of established cultures, collapse of family and community life, loss of rural and urban livelihoods, species decline, degradation of ecosystems and of air, land and water, draining of non-renewable energy resources, and climate disruption.
We believe the approach proposed here will produce papers that will complement those already now published, and translated into public policies and programmes will further protect public health, national and local culture, rural and urban employment, rational food systems, the living world, the environment and the biosphere.
1. BMJ. Food for thought: The science and politics of nutrition https://drive.google.com/file/d/1LJub2yZKrY2bZ7W_UlVlIkW-k1dEiVyY/view
2. BMJ. Food for thought: The science and politics of nutrition. June 2018, ISSN 2057-0066. https://www.bmj.com/food-for-thought
3. Peplow M. No time for stodgy: Crusading editor aims to shake things up in science. Stat January 4, 2016. www.statnews.com/2016/01/04/bmj-editor-fiona-godlee/
4. Adams J, White M. Characterisation of UK diets according to degree of food processing and associations with socio-demographics and obesity: cross-sectional analysis of UK National Diet and Nutrition Survey (2008–12). International Journal of Behavioral Nutrition and Physical Activity 2015; 12:160. https://doi.org/10.1186/s12966-015-0317-y
5. Monteiro CA, Moubarac J-C, Levy R, Canella D, Louzada M, Cannon G. Household availability of ultra-processed foods and obesity in nineteen European countries. Public Health Nutrition 2017; 1-9. doi:10.1017/S1368980017001379 S
6. Juul F, Martinez-Steele E, Parekh N, Monteiro CA, Chang V (2018). Ultra-processed food consumption and excess weight among US adults. British Journal of Nutrition 2018; 1-11. doi:10.1017/S0007114518001046
7. Baraldi LG, Martinez, Steele E, Canella DS, Monteiro CA (2018). Consumption of ultra-processed foods and associated sociodemographic factors in the USA between 2007 and 2012: evidence from a nationally representative cross sectional study. BMJ Open 2018; e020574. doi:10.1136/bmjopen-2017-020574
8. Rauber F, da Costa Louzada ML, Steele EM, Millett C, Monteiro CA, Levy RB. Ultra-processed food consumption and chronic non-communicable diseases –
related dietary nutrient profile in the UK (2008–2014). Nutrients 2018; 10, E587.
9. Monteiro CA, Moubarac J-C, Cannon G, Ng SW, Popkin B. Ultra-processed foods are becoming dominant in the global food system. Obes Rev 2013; 14:21-28. doi: 10.1111/obr.12107
10. Louzada M, Ricardo C, Steele E, Levy R, Cannon G, Monteiro CA. The share of ultra-processed foods determines the overall nutritional quality of diets in Brazil. Public Health Nutrition 2017; 1-9. doi:10.1017/S1368980017001434
11. Cediel G, Reyes M, Da Costa Louzada M, Martinez Steele E, Monteiro CA, Corvalán C, Uauy R. Ultra-processed foods and added sugars in the Chilean diet (2010). Public Health Nutrition 2017; 1-9. doi:10.1017/S1368980017001161
12. Marrón-Ponce J, Sánchez-Pimienta T, Louzada M, Batis C. Energy contribution of NOVA food groups and sociodemographic determinants of ultra-processed food consumption in the Mexican population. Public Health Nutrition 2017; 1-8. doi:10.1017/S1368980017002129
13. Julian C, Martinez L, Allès B, Touvier M, Hercberg S, Méjean C, Kesse-Guyot E. Contribution of ultra-processed foods in the diet of adults from the French NutriNet-Santé study. Public Health Nutrition 2017; 1-11. doi:10.1017/S1368980017001367
14. Kim S, Moon S, Popkin BM. The nutrition transition in South Korea. Am J Clin Nutr. 2000 Jan;71(1):44-53.
15. Monteiro CA, Cannon G, Moubarac J-C, Levy R, Louzada M, Jaime P. The UN Decade of Nutrition, the NOVA food classification and the trouble with ultra-processing. Public Health Nutrition 2017; 1-13. doi:10.1017/S1368980017000234
16. Monteiro CA, Cannon G. The impact of transnational ‘Big Food’ companies on the South: A view from Brazil. PLoS Med 2012; 9(7): e1001252. https://doi.org/10.1371/journal.pmed.1001252
17. Moodie R, Stuckler D, Monteiro CA, Sharon N, Neal B, Thamarangsi T. Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. Non-communicable diseases series 4. The Lancet 12 February 2013. http://dx.doi.org/10.1016/ S0140-6736(12)62089-3
Competing interests: No competing interests
In the conventional indoor case paper , a column at the extreme right carries the heading 'diet' , meaning thereby that medicines plus the recommended diet comprises the 'whole' of disease management. Not confined to disease states , nutrition signifies a lot to preservation of sound health , promotion of health in situation of pregnancy and altered requirements . The nutritional epidemiologic transition to fast foods ( sometimes considered junk) has contributed to non communicable diseases- metabolic syndrome, diabetes mellitus and coronary artery disease. Two facts emerge- deficiency in diet when corrected deliver remarkable clinical results -iron , B12, vitamin C, thyroxin , proteins , etc. However mere measurements do not suffice : timing of food , season and weather , appetite , state of mind and mood could contribute to assimilation and affect anabolism. Seasonal and natural easily scores over processed , preserved and flavoured . Finally , behavioural changes pertaining to dietary restrictions tend to work short term only ; long term compliance to say salt restriction can be erratic bordering on failure. Murar E Yeolekar , Mumbai.
Competing interests: No competing interests
Thanks for your well written articles on the bmj.
As you say there are many difficulties with proving food and dietary effects. However many of us feel there is enough convergence of evidence to recommend a whole foods, plant based diet (‘healthy vegan’). For smoking there were around 7000 studies before it was accepted that it caused disease and guidelines changed and it seems the same paradigm with food. Doctors smoked and received tobacco money and slowed the making and guidelines for smoking cessation.
The majority of evidence supports eating mostly (only?) whole plant foods and the only reason to hang onto eating animal flesh and products would appear to be custom, taste and financial interest. Certainly it isn’t in the wider public health or environmental interest to do so, animal agriculture related activities accounting for a major proportion of our carbon emissions.
Many of us have joined the dots and practice ‘plant based’ nutritional medicine to amazing effect, far more than the pills we prescribe in our palliative form of medicine we practice today. Given the right fuel the body tries to heal itself, as seen in Ornish and Esselstyn’s cardiovascular studies, Barnard’s diabetes studies and ornish’s prostate studies showing not just halting but reversal of disease.
From an evolutionary point of view most (all?) of our adaptations are of a frugivore not Omni nor carnivore which gives us a clue to why this diet is so beneficial. Millions of years of trial and error create a close link between organism and benefits of the right food.
I recommend reading the NZ BROAD study if you haven’t. These trials aren’t easy to do but if they work, people stick with them. Roy Swank’s incredibly successful 34 (-50) year MS low sat fat study attests to this. One of most incredible studies in medicine, which most people come out of medical school or practicing are unaware of, as I was.
I look forward to reading more on this in future BMJs and articles , as the public are onto it and bypassing doctors for nutrition advice.
GP with interest in nutrition and lifestyle medicine, Auckland
On behalf of world wide plant based nutritional practitioners.
Competing interests: No competing interests
Most, perhaps all articles and studies are empirical. I did not find adequate evidence of mathematical models of the biochemistry/biophysics of nutrition in health and disease. To me, this is a critical flaw.
The human body has about 25K to 50K molecules or biomarkers constantly changing (via a HUGE number of chemical reactions). Healthy life expectancy or morbidity or mortality from cardiovascular disease (CVD) or cancer is a function of these biomarkers. However, it is practically impossible to measure all of them (and they change with time, environment, diet, etc.).
According to my theory, the relationships are usually in the form of an inverse U (with longevity in the Y axes, other variables in the other axes). It means that for most biomarkers, particularly nutrients, we need them in a narrow range for optimal desirable outcomes. Too little or too much leads to undesirable outcomes. Further, the optimal range for one nutrient depends on the values of other nutrients in the body. Because empirical studies rarely measure all known nutrients (and never all known molecules), it is impossible to know whether the results of a study will change direction if the person had different genes or different concentrations of other nutrients. In practical terms, one person may need more Vitamin D while another may need less Vitamin D (depending on their body composition).
Without an adequate biophysical model of the body and principles similar to those of physics and thermodynamics (e.g., the law of least action, conservation of mass, etc.), we cannot decide how to interpret data or decide optimal nutrition.
Researchers ought to describe the state of the art as follows:
What are the known key relationships among nutrients? What is conserved? What is converted to other? Ex: intake of carbs not used for energy are converted and stored primarily as saturated fatty acids. Intake of omega-3 fatty acids are not converted to omega-6 fatty acids (or vice versa). Protein can be converted to glucose or carbs or saturated fatty acids but not PUFAs. Glucose cannot be converted to protein or PUFAs.
What are the fundamental relationships or concepts that are not known? What mathematical models exist (if any) explaining the different roles of nutrients? Can we approximately predict the plasma levels of cholesterol and triglycerides from dietary intake (not based on empirical data, but based on a theory, a math model)? What theoretical relationships exist between lipids, fatty acids, vitamins, minerals? What about O2, blood pressure, cancer cells. Are there theories that predict the effect of different nutrients on O2 or BP or cancer cell reproduction? Are most modern disorders linked primarily to genes or diet or environment? What are the relationships between the enzymes (determined by genes), the nutrients, and healthy life expectancy? What factors determine how long we live and why (not empirical data, but mathematical hypothesis leading to thought experiments).
My point is that there are practically unlimited empirical descriptions of data in medicine, but only a few biophysics models that accurately predict health and disease. Where are they? Can we have a “list” or “review” of existing models, their strengths and limitations? Consider two simple concepts. The values of lipids (cholesterol and triglycerides), and the survival and reproduction of cancer cells. What models exist that make quantitative predictions about lipid values or cancer cell survival based on dietary intake? If none exist, then authors should acknowledge that and “think” what the models should do. Asking the proper question is essential to lead us to better answers.
Siguel, E. A New Relationship between Total/HDL Cholesterol and Polyunsaturated Fatty Acids. Lipids, 1996; 31, S51-S56.
Siguel EN. Essential Fatty Acids in Health and Disease. 1994. (book, Amazon.com).
Competing interests: Competing interests: I conduct many activities that influence my opinions (e.g., my research, write books or articles or patents, have websites, design foods, lecture about health and disease, health policies). I describe the types of fats to eat, exercise, stress management, diets, eating less, periodic fasting. I am developing a new theory of disease, including lipid metabolism and the cause of cardiovascular disease, cancer and other conditions, with new treatments. I intend to profit from my intellectual property (IP) (e.g., write articles, web sites, books, patents, lectures, ads, biomarker tests, seek financial support, venture capital, etc.). I wrote a US patent to measure fatty acids. I wrote one book on essential and trans fatty acids (amazon.com). I gave talks to corporations, conferences and trade shows, for which I was paid (mostly on fats). I may receive compensation from food or other companies. This comment is an extract of books and articles either written or in progress (comment authorized by the author under the non-exclusive common license CC BY-NC 4.0 requested by BMJ). I criticized the value of the USDA nutrition guidelines, federal nutrition funding, and the National Cholesterol Education Program. I do not consider eggs harmful because they have cholesterol and fat, made my views public, received funding from egg industry. I tell my family to eat eggs and red meat, avoid processed fat. I do not follow the USDA nutrition guidelines. I proposed a different Food pyramid and nutrition guidelines. To me, nutrition is the most important factor in health and disease and I write that doctors should learn more about nutrition and spend more time with patients. I write that many blood, invasive, and diagnostic tests using energy (e.g., endoscopies, X-rays, ultrasounds) are overutilized and harmful. Many of my writings are found via a search for Siguel and Fatty Acids or Siguel in BMJ.com responses. Soon at essentialfats.com, EFA.com, optimalpolicies.com