Healthier people need healthier foods

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0:00:04.8 Sue Cole: Nutrition matters with respect to the health and well-being of a community. If we consider members of the community, a healthy diet is essential for the growth and development of children, as well as supporting healthy pregnancies and breastfeeding women in the community. Nutrition matters for the healthy aging of adults and across the life stages from infancy to older adults, a healthy diet plays a key role in chronic disease prevention, and in both children and adults a healthy diet support immune function, the health of our digestive tract or our gut, as well as strengthening bones.

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0:00:50.8 Speaker 2: It's no secret that healthier food makes for healthier people, but there can be challenges to overcome when trying to make healthy food choices for ourselves and our families. For one thing, not all foods are created equally nutrition-wise. In fact, many highly processed foods can actually have adverse effects on our health.

0:01:09.8 S2: There are many communities in the US and beyond that do not have ready access to affordable, high quality food for a number of reasons, and the economics of food production plays a large role in the availability of fruits and vegetables, which tend to cost more to grow and harvest. Thank goodness that public health researchers are studying all these problems and coming up with clever effective solutions.

0:01:33.9 S2: Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. Join us as we dig into important health topics, stuff that affects the health of all of us at a population level, from the microscopic to the macro-economic, the social, to the environmental, from cities to neighbourhoods, states to countries and around the world.

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0:02:02.1 S2: Sue Cole is a lecturer in Nutritional Sciences at the University of Michigan School of Public Health. We started our conversation with her by asking, what exactly are processed foods? 

0:02:11.9 SC: There is no unified definition of processed foods, but one approach to thinking about process foods has been proposed by the Academy of Nutrition and Dietetics, that is there's a continuum of food processing that ranges from minimally processed foods to highly processed foods.

0:02:31.6 SC: So for example, minimally processed foods, just as they sound, are foods that undergo minimal processing, such as cut fruit or vegetables in the grocery store where you see cut up cantaloupe in a plastic container, that would be an example of minimally processed foods. Leafy greens such as collard, spinach and kale in a bag, that's another example of a minimally processed food.

0:02:58.0 SC: The next in the continuum would be foods that are processed a bit further, such as canned green beans, canned tomatoes and frozen vegetables and so forth. And in some of these foods, there may be an additional ingredients, such as salt or added sugar or oil, such as in the case of caned tuna.

0:03:17.2 SC: Further on the continuum are foods that contain ingredients, that enhanced flavour and impact texture. So for example, flavoured yogurt may have a thicker added to improve its consistency or its texture as well as added flavours. And then finally, at the very end of the spectrum is highly processed foods that include ready to eat, sometimes these are called "ultra-processed foods". And these include salty snacks, hot dogs, frozen pizza, deli meats, pre-made meals that are microwaveable, and sugary drinks.

0:03:57.6 SC: It's important to recognise that processed foods are convenient. If I make soup at home, I may not have time to cook pinto beans or kidney beans from scratch, soaking them and boil them, so forth. I may just pop the can of kidney beans and add it to my soup. And precut vegetables and fruit, and again, bagged greens are very convenient. Most of us don't have time to bake bread at home, and so being able to purchase a loaf of bread is convenient.

0:04:32.3 SC: The concern is when there's a heavy reliance on these processed foods, and so here I'm not referring to the minimally processed leafy greens, but the highly processed ready to-eat foods and beverages, and these foods are often high in sodium, added sugars, saturated fat and typically low in dietary fiber. They also tend to be high in calories.

0:04:53.6 SC: The other concern is that two recent studies found that over 50% of US diets that includes adults and children are composed of highly processed foods. A high consumption of these processed foods is associated with increased weight gain, hypertension or high blood pressure, which increases the risk for cardiovascular disease, and cancer.

0:05:20.7 SC: As I mentioned earlier, processed foods are generally high in sodium. Sodium is added to foods for food safety, that is to prevent microbial growth. Salt is also used to enhance flavour and it's required in some baked products, but the problem here is that there's too much sodium in our food supply. US adults on average consume 400 milligrams of sodium per day, and this is in contrast to the dietary guidelines which recommend that adults consume less than 2300 milligrams per day.

0:05:56.9 SC: High salt intake is a significant public health concern since it contributes to high blood pressure or hypertension, which increases the risk of cardiovascular disease. What's interesting is that the major sources of sodium in the US diet does not come from salt added at home in food preparation or at the table, but rather the salt comes from processed foods and restaurant foods outside of the home.

0:06:24.2 SC: If we could dial down the amount of sodium in the US food supply, especially foods that contribute significantly to sodium intake such as processed foods and prepared foods from restaurants, that could potentially reduce the amount of sodium in US diets. The FDA collaborating with food industry developed and approach to gradually reduce sodium in processed and restaurant foods by issuing voluntary sodium reduction targets for foods.

0:06:56.5 SC: The plan is a modest reduction in sodium in processed and restaurant foods for over two and a half years. The FDA will be monitoring the sodium content of US foods over the next few years, as well as industry's progress, and at this stage of the plan, the sodium reduction targets are not mandatory, in order to provide companies time to make adjustments in their food products, as well as restaurants to adjust recipes, though a number of companies in the US have already begun sodium reduction of their products.

0:07:29.9 SC: The goal is to reduce the average sodium intake from 3400 milligrams per day to 3000 milligrams per day over the next two and a half years, and the expectation is that additional reductions of sodium or new sodium targets will be issued after two and a half years, or at that time once the FDA is completed its monitoring.

0:07:54.7 SC: The long-term goal is to reduce the average sodium intake to less than 2300 milligrams per day. This would be a substantial public health accomplishment if this plan is able to result in a reduction from 3400 to 3000 milligrams, and if future iterations continue to reduce sodium content of the US food supply.

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0:08:27.2 S2: Processed or not, it's clear that what goes into our food during production has a huge impact on human health. But what about our food's impact on the environment? Dr. Olivier Jolliet is a professor of Environmental Health Sciences at the University of Michigan School of Public Health. He studies environmental life cycle assessment. That looks at the environmental impact of production through the life cycle of a food product, to measure risks and impacts on human health and the environment.

0:08:52.7 SC: Using the Health Nutritional Index, or HENI, Dr. Jolliet's research team has established a way to calculate the minutes of human life gained or lost by eating a single serving of specific foods. This research can help people make better food choices for their health and for the environment.

0:09:09.5 Dr. Olivier Jolliet: When we eat something on our plate, it has a long history, and that's a role of life cycle assessment, to follow each step of that history. When we do life cycle assessment, we look at the emission for feed production, for the animal production, that cheese itself processing, and what's happening at the consumer, your fridge also emission or use of electricity, and eventually the disposal of all the different waste which are happening across the chain.

0:09:37.9 DJ: Let us take a Swiss or piece of Gruyere. This cheese, first you will have perhaps some fertiliser which have been produced to produce the grass, or you will have some manure applied on the field. Then the grass or for US it's more corn and soybean, which is growing and will be probably transported from the place where it's grown. Some farm have, grow their own crop themself. Or if it's pasture it's grown locally.

0:10:09.9 DJ: But then it's transported to the farm where you have the animals and then the animal concerned, the milk is taken, and then our milk is transported to milk processing facility where it will be processed and pasteurised, then you will have the manufacturing of my cheese. Then you have the distribution, again, transport to the consumer. You are going to the shop to get your cheese.

0:10:37.5 DJ: Overall, all that, each of these step has some impact. Sadly, so far in the US, we are losing 30% of the food, which we could by just avoiding that, we could also reduce by a third our impact. The foot we eat, and especially the red meat we are eating and the beef, has substantial impact.

0:11:01.7 DJ: Compared to other type of food, the beef is twice higher, is like 4 kilogram of CO2 emitted per serving of beef, is twice higher than what we have with pork and lamb, and four times higher than the dairy or the chicken, and then 10 times higher than many of the plant-based food. So we have a lot of room for improvement just by reducing and avoiding certain type of foods like beef on the environmental side.

0:11:33.9 DJ: So by changing 10% of our calorie, reducing or avoiding processed meat and beef and replacing it by a mix of healthy food, we can reduce our dietary carbon footprint by 30% or even a bit more, and we can also gain about 48 minutes per person per day. In general, I would say that most food which are better for the health are also better for the environment. It's not always correlated.

0:12:05.6 DJ: To reduce the environmental impact, moving towards a vegetarian-based diet is in fact more important than, for example, taking organic food instead of conventional food, where if you have organic food, you reduce a bit your production, you reduce also your impact, but as a whole per kilo produce, you are in the same range. Whereas changing from meat-based to more healthier has both the gain for nutrition on and for the environment.

0:12:34.4 DJ: Our plan is in fact to have both the environmental impact and the nutritional HENI score in minutes of life gain and loss available in an app. In such an app, people putting, like for breakfast they can choose what they have eaten today or what they're going to plan to eat, and automatically then the app will take this, define the typical portion or ask you how much you have eaten, and build up diary of what you are eating on a regular basis in a very easy way.

0:13:05.2 DJ: And so once people have that, they can really follow up and follow how they are doing and improving with time, and also test some alternative, if I change that, how will it change my diet and my performance. It will speak of both the environment and they will have their carbon footprint, additional impact on human health and biodiversity, and then on water and land use.

0:13:26.0 DJ: So they will have that on the one end, and then they will have the minutes of life gain, and they can see where they could improve in a sense, and we can start showing them, is it whole grains which is missing in the diet, where they could make the most improvement, or what also are the most detrimental food item they are eating and they should replace.

0:13:46.3 S2: But individuals alone can't change the global food system. To achieve healthier, more environmentally sustainable food production practices, the real work needs to start at the source. Public health scientists like Dr. Jolliet often work together with food producers to find ways to build better processes in our food systems. He explained to us why it's important to build these relationships between public health and business.

0:14:09.4 DJ: 2006, Walmart starts to ask scorecards on packaging from their producer, which was life cycle based. An impact assessment method called TRACI, which is interesting. This model, TRACI, is called an impact assessment, so it looks at impact on global warming, on nitrification, on the environment, on water, on different parts and also on pesticide and toxicity.

0:14:36.5 DJ: It was not great, I had some criticism to it and they improved it substantially afterwards, but suddenly you had 65,000 suppliers which were asking, "What is life cycle?" and it made more for our field than any legislation that you could have. So distributor really have the power to orientate in their offering, and also to promote prices of what is the most affordable and the most sustainable here.

0:15:06.4 DJ: Coming from a life cycle assessment background rather than a risk assessment, for example, background where I see the difference, usually the industry who are asking for a result and services are interested to improve, and they do it voluntary, it's not a legal point, and they do it because they want to know their strengths, but also to know their weaknesses and work on addressing these weaknesses.

0:15:32.2 DJ: And that's what a good proactive industry wants, and I think working with industry is our chance to make a difference in the world. With these minutes of life gain and loss, we are giving advice to consumers and their understanding and it's useful, but it's also important that a producer realise the importance of producing more healthy food, or not adding too much sodium to your dishes, for example. And this is by working together.

0:16:00.5 DJ: Life is not so simple, and on average, it's not about banning one product, it's really about continuous improvement. I think we can help industry in that case internally of improving our diet and which policy could help that. I think we can add on the production side, and that's where the subsidies subsidising foods which are healthy and sustainable in priority, and that would be a big switch, but a switch which is I think feasible to reorientate the subsidy there.

0:16:30.2 DJ: And then of course, on the consumer side is also important to stimulate the choice of healthy food, especially in schools, to have healthy, affordable and palatable, we want the taste also, tasty food which are healthy and really stimulate that. But I think working on the two ends simultaneously would help a lot.

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0:16:55.9 S2: So how did we get here? Why is our food system already so congested with cheap nutrient-poor foods? Sue Cole says policy around what's grown and produced is a driving force.

0:17:09.1 SC: There's several factors that contribute to why healthier foods may be more expensive than processed foods. In the US, commodities such as corn, wheat and soy are subsidised and supported to a much greater extent when compared to healthier foods such as fruits and vegetables. Corn, wheat and soy are used in the manufacturing of processed foods, thus subsidising and promoting these crops supports processed food manufacturers.

0:17:39.2 SC: Processed foods are manufactured in factories, and so they can be produced in very large quantities as compared to healthier foods such as fruits and vegetables, which are limited by growing capacity and so forth. Also, corn, wheat and soy can be harvested by machines, whereas human labour is used to harvest many fruits and vegetables.

0:18:04.0 SC: And finally, processed food manufacturers have a very strong lobbying presence in our government, influencing the policies and subsidies over the basic commodities that are used to produce these products. Access to healthy foods is essential for the health of a community, and disparities in accessing healthier foods is a key factor in nutrition and health inequity.

0:18:30.3 SC: So for example, poor access to healthy foods can occur in communities that have predominantly small grocery stores or convenience stores that largely stock processed foods. These small stories may have limited options for healthier foods, and those they carry are often expensive.

0:18:50.9 SC: These communities often lack large supermarkets that stock a greater variety of foods that are generally more affordable. This, coupled with the availability of fast food establishments which generally sell calorie dense, nutrient poor, high sodium, high added sugars, processed and prepared foods. This creates a environment of lower quality foods and poor healthy food access. Lack of transportation to supermarkets or larger grocery stores is another factor that contributes to nutrition and health inequity in communities.

0:19:30.6 SC: I believe that public health plays an important role in reducing nutrition and health disparities in communities, through improving awareness of barriers to healthy eating, supporting community initiatives to address diet quality, as well as conducting research to identify effective policies and programs that improve healthy food access.

0:19:49.8 SC: But public health cannot solve inequities in isolation. Rather, in coordination with government agencies that are involved with supporting and subsidising healthier foods such as fruits and vegetables, and supporting farmers that produce those crops, as well as communities that are implementing initiatives such as the Healthy Corner Store Initiative, or that have land use policies that are promoting community gardens and so forth.

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0:20:28.6 S2: Alumni Ariane Donnelly is leading one such program aimed at getting healthier whole foods to those who need it. Donnelly works for the Washtenaw County Health Department and leads the Prescription for Health program, a food assistance program that provides a connection between the medical system and the food sector, and uses accessible farmers markets to help people achieve their health goals through improving their food choices.

0:20:49.4 Ariane Donnelly: I always like to start thinking about this as the cartoon that we always like to refer to. So there is a farmer, and above him is a sign that says "pharmacy", but spelled F-A-R-M-A-C-Y, and he's giving a head of lettuce to his customer, and saying, "Take one a day with tomato and cucumber."

0:21:09.2 AD: So that's really how we envision our program, is that food is medicine, food can be medicine. And good food equals good health. Farmers markets provide a way for community members to buy fresh and affordable agricultural products, while supporting local farmers, and farmers markets often emphasise the nutrition and support customers to cook healthier meals and maintain good eating habits.

0:21:36.3 AD: A diet comprised of nutritious foods in combination with an active lifestyle can reduce the incidents of heart disease, cancer and diabetes, and it's essential to maintain a healthy body weight and prevent obesity. We're here to really provide resources and support to our participants as we decide to make healthy eating and living goals and changes.

0:21:55.4 AD: How this actually got started is, public health community assessment data were showing low produce intake and high obesity rates and rates of chronic disease. So with high food insecurity plus low consumption of fruits and vegetables, that equalled increased chronic disease risk, and thinking about healthy food resources and lack of healthy food resources.

0:22:21.0 AD: But farmers markets are these wonderful places, lots of access to fresh local produce, but they may be unfamiliar places to many community members. And sometimes there's a disconnect to the medical model. So for example, clinics may recommend healthy eating changes and give nutrition advice, but patients face multiple barriers and need support in setting and achieving goals for behaviour change.

0:22:42.8 AD: So thinking about all those factors, it was how can public health support change? We start with the clinic setting, and that patients will come to the clinic and then the clinicians who are there, they're going to recruit participants who would meet three referral criteria. One is that they're food insecure for fruits and vegetables, meaning that they can't afford those items for themselves.

0:23:06.4 AD: Two, is that they're at risk for chronic disease, so either they currently have a chronic disease like high blood pressure, diabetes or obesity, or they're at risk for developing that. And the third one is that they're able and willing to use the program. We give them a packet that really fully explains the program, where they can go to spend their tokens that we're gonna give them on fruits and veggies, so which of our farmers market partners and farm stand partners they can go to spend those.

0:23:35.8 AD: And we give $100 in tokens and that $100 can be spent on fresh fruits, fresh veggies, or fruit and vegetable plants or seeds. And part of some of the resources that we talk about, we also talk about which farmers markets that we partner with that participate with the Supplemental Nutrition Assistance Program, aka SNAP, aka Bridge Card, EBT, food stamps. So that's another huge benefit.

0:24:02.3 AD: Every year of our program we've had north of 400 participants each year and each season. The participants are referred from 13 different health clinics and agencies serving low income individuals. People who are referred into our program, they're ready to make healthy eating and living changes, they already have goals in their mind, so our program just kind of helps them formulate those goals and helps them set the baby steps to reach those goals.

0:24:29.3 AD: Pre-program to post-program from 2011 to 2019, participants had a statistically significant increase in their self-reported intake of daily fruits and vegetables. Participants have lost weight, they were able to stop taking a medication, for example, for high blood pressure. People have told me that they were pre-diabetic, but that they've reversed that as a result of the program. Countless amazing stories of people being able to be more active than they were previously. Someone mentioned they were able to sleep at night while they were on the program because they were no longer hungry.

0:25:07.8 AD: We do have new participants every year in our program, but we also do have participants who have participated before in our program. Unfortunately, food insecurity doesn't always go away, and we don't wanna restrict anybody from being able to participate in our program, and we want to continue to be a resource for them.

0:25:26.8 S2: Programs like Prescription for Health work because they're collaborative. When balance can be achieved within someone's nutrition, healthcare and community, it makes a healthier lifestyle more accessible.

0:25:37.3 AD: We like to also think of our Prescription for Health program as a three-legged stool, and that for each arm of the stool, one is us, is the local Public Health department, but then also our farmers market and Farmacy partners is the second leg, and then the third would be our referring agencies, those clinics and our social service agencies who refer people into our program, and our program cannot function without one of these legs.

0:26:01.9 AD: The partners that we work with, most of them are social workers or registered dieticians or patient advocates, and so they really have more time that they can sit down with the patient to really talk about what more of these are issues that are being reflected in their health. We could go back to the clinician and say, "Oh, we haven't seen so and so yet at the market, and we haven't been able to reach them. Has their phone number changed? How can we reach them? Can you talk to them the next you're there?" And then it really opens up that line of communication.

0:26:38.2 AD: Because we all have the same goal, it's all about wanting to make our community healthy and help them to live in the way that they want to, and have the behaviour changes that they want to enact. When thinking about how this $100 can stretch and have this impact, one is it's monetary, in that people are being able to access fruits and vegetables that they otherwise wouldn't be able to.

0:27:00.6 AD: And then it's that social capital, that's another benefit. They talk about all the time about how the farmers markets are a safe place where they felt like they could shop, especially during the pandemic, because they were outdoors, but also how this was kind of their social event. They would go and that they formed to get relationships with everybody at the market, including the farmers.

0:27:21.4 AD: When someone enters our program, it's not just about the money, it's also about the relationships that they build and also the connection to the other resources. It creates this social connection between the participants and the farmers markets, and that I think is such a beautiful relationship because it also really continually highlights how our farmers care for us, and care for us as a community.

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0:27:53.6 S2: On the next edition of Population Healthy.

0:27:57.0 Speaker 5: When I think about what HIV looks like now versus 1981 or 1985, I think that we have made amazing strides in terms of medication. Early on, a death sentence. Today, really it's a chronic illness. I think there's been a big shift in acceptance of people living with HIV, but I do think that it is not where it needs to be. I think stigma is still the number one facilitator of HIV because there's so much stigma people are afraid to talk about it, afraid to disclose, afraid to get tested still. Things like that.

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0:28:38.7 S2: Thanks for listening to this episode of Population Healthy, from the University of Michigan School of Public Health. We're glad you decided to join us and help you learn something that'll help you improve your own health or make the world a healthier place. If you enjoyed the show, please subscribe or follow this podcast on iTunes, Apple Podcast, Google Play, Stitcher, Spotify, or wherever you listen to podcasts.

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0:29:15.1 S2: Visit publichealth.umich.edu/news/newsletter to sign up. You can also check out the show notes on our website, Population-Healthy.com for more resources on the topics discussed in this episode. We hope you can join us for our next edition, where we'll dig in further into public health topics that affect all of us at a population level.

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