Can food policy changes make America healthy again?

Shortly after Donald Trump because the only politician since Grover Cleveland to be re-elected to a non-consecutive second Presidential term, I discussed why Robert F. Kennedy, Jr.'s conspiracy-fueled positions on childhood vaccines and fluoridated drinking water make him unqualified to be the next Secretary of Health and Human Services (HHS). Now that the newly inaugurated President has withdrawn the U.S. from the World Health Organization, presumably paving the way for RFK Jr., if confirmed as HHS Secretary, to "go wild on health," it's time to examine the other side of "Make America Healthy Again": his more mainstream belief that overconsumption of ultra-processed food is the cause of a wide spectrum of chronic health problems.

A side note: medical historians have pointed out that the "again" part of the MAHA slogan, harkening back to a time in the past when our country was healthier than it is today, is nonsensical, as in no past era have Americans lived longer or had a better quality of life with less disability than today. The 19th century, for example?

It’s true that agriculture at the time was organic, food was locally produced and there were no ultraprocessed foods. But fresh fruits and vegetables were in short supply because they were difficult to ship and because growing seasons were so short. ... Common conditions, like hernias, were untreatable — men had hernias as big as grapefruits, held in by trusses. Nineteen percent of those soldiers had heart valve problems by the time they were 60, compared with about 8.5 percent today.

And of course, many thousands of people - mostly young children - died every year from infectious diseases like smallpox, polio, and measles, which have been eradicated or are completely preventable by vaccines that RFK Jr. claims are worse than the diseases. Has he ever seen an iron lung up close? But I digress.

The U.S. government has always had competing interests in food policy. As NYU nutrition professor Marion Nestle (whose engrossing autobiography "Slow Cooked: An Unexpected Life in Food Politics" I read over Christmas break) observed, having the Dietary Guidelines for Americans co-sponsored by HHS and the U.S. Department of Agriculture (whose missions are to help farmers profit from the products they bring to market and to prevent poor people from going hungry by subsidizing food purchases, not to support good health) means that scientifically obvious statements such as "eat less meat" or "drink less alcohol" rarely make it into the guidelines. And opposition from powerful food companies makes even modest changes such as the FDA updating criteria for labeling foods "healthy" and requiring food and beverage products to display amounts of fat, salt, and added sugar at a glance painfully slow.

So what's the evidence that ultra-processed foods lead to obesity and other chronic diseases? A recent systematic review of meta-analyses of observational studies found convincing or highly suggestive links between ultra-processed food exposure and cardiovascular disease, diabetes, anxiety, all-cause and cardiovascular deaths, depression, sleep problems, wheezing, and obesity. Observational studies are susceptible to selection bias, though - perhaps preferring inexpensive highly processed foods is associated with poverty, and poverty itself increases the risk of dying early and unhealthy behaviors, explaining these disease associations.

It's difficult, but not impossible, to randomize study participants to controlled diets; one research team managed to convince 20 adults to participate in a 28-day experiment at the National Institutes of Health that concluded that all other things being equal, people were more likely to consume excess calories and gain more weight on a diet of ultra-processed foods compared to an unprocessed diet. (For further reading, a recent New Yorker article went behind the scenes of this highly cited trial and the debate about its implications that continues to rage in food science circles.)

But the unqualified conclusion "ultra-processed food is less healthy than unprocessed food" is too simplistic, particularly when meat is involved. The plant-based Impossible Burger is clearly ultra-processed, but is it really less healthy than a minimally processed hamburger patty made from ground beef from cows raised on industrial farms? A review of plant-based meat alternatives (PBMAs) in the Canadian Journal of Cardiology found that their nutritional profiles were generally superior to the meats they replaced and improved cardiovascular disease risk factors in dietary trials. The authors concluded that "no currently available evidence suggests that the concerning aspects of PBMAs (food processing and high sodium content) negate the potential cardiovascular benefits."

Which leads me back to RFK Jr.'s crusade against ultra-processed foods. I think implementing this would be an uphill battle because making foods healthier will necessarily require creating more regulations in an administration committed to deregulation. If he's serious about asserting more control over our food production and distribution system to limit ultra-processed foods in the interest of improving Americans' health, RFK Jr. would do well to read Marion Nestle's aspirational agenda for regulating the food industry, which includes actions to take on dietary guidelines, mass media campaigns, taxes, warning labels, marketing restrictions, portion size restrictions, and farm subsidies.